- F.t _ tl ,a~ ai 9 itf r ,et -

ar ',

r ;R

p - ,-AG 1 t

. r

~ . 4 1

by a

WI,

WOOI) LIBRARY-MUSEUM

OF ANES1'IIESIOLOGY

AN ESSAY, &c.

.

AN ESSAY

ON

THE MEANS OF LESSENING PAIN,

AND~

JactItattn ~ertatn Ia~e%

OF

DIFFICULT PARTURITION.

BY WILLIAM P. DEWEES, M. D.

LECTu RER ON MIDWIPER? IN FUILADELPIA4, &C.

Cceeus iter monstrare ,elit--HOB.

SECOND EDITION.

PHILADELPHIA.PUBLISRED BY THOMAS 0O01S0N AND SON, AT THE STONE

HOUSE, No. 41, SOUTH SECOND STREET.

William Fry, Printer.1819.

Eastern District of Pennsylvania, to wit:

'I BE IT REMEMBERED, that on the ninth day of Fe-+... hrury, in the forty-third year of the Independence of the

United States of America, AD 1819, Thomas Dobson andSoni, of the said district, have deposited in this office the title of a bookthe right whereof they claim as proprietors, in the words following,to wit.

"An Essay on the Means of Lessening Pain, and Facilitating Cer-tain Cases of Difficult Parturition. By William P. Dewees, M.D.Lecturer on Midwifery in Philadelphia, &c.

-_-_-_--"-ut sicawcus item monstrare velit.--Uor.

Second edition."

In conformity to the act of the Congress of the United States, inti-titled, "An act for the encouragement of learning, by securing thecopies of maps, charts, and hooks, to the authors and proprietors ofsuch copies, during the times therein mnentioned."-Arid also to theact, entitled, "an act supplementary to an act, entitled, "an act for theencouragement of learning, by securing the copies of maps, chars, andbooks, to the authors and proprietors of such copies (luring the timesthierein mentioned," and t xtending the benefits thereof to the arts ofdesigning, engraving, and etching historical and other prints."

D. CALDWELL,Clerk of the Eatern histrict of Fen lvvan a-

N. CHAPMAN, M. D.

c. c. c .

DEAR SIR,

Permit me to inscribe this humble Essay

to you; and be pleased to look upon it as a

sincere though feeble expression of the regard

of

Your obliged Friend,

WM. P. DEWEES.

Philadelphia, December 6th, 1818.

PREFACE.

THE greater part of the following pageswere an Inaugural Dissertation; the principles

and practice contained in them, were the re-suit of seventeen years extensive business andcareful observation; the experience of twelveyears since, has but confirmed them. The au-thor, therefore, conceived that by republish-

ing them with some additions and corrections,he ran no risk of doing mischief, should hefail in a sincere desire to do good.

He is persuaded that, up to the presenttime, no remedy has yet reached us of equalefficacy, for the particular cases for which itis prescribed, as the one he ventures to re-commend in this Essay, and is fully convinc-ed there is none safer. He must, however, begof those who may feel disposed to rely upon

iivu.

it, to give it a fair and unprejudiced trial; to

carefully discriminate the several varieties and

conditions pointed out, and to apply the means

to the extent proposed, and in the manner

and under the circumstances designated; with

an attention to these injunctions he feels a

perfect reliance that no one will experience

a disappointment who may adopt it.

The short time which was allowed to fur-

nish a Thesis, prevented any correction of

the press; in consequence of which many

errors in the printing, as well as of the opi-

nions, were unavoidably promulgated, and

this perhaps to the injury of the author; he

has, however, endeavoured in this edition to

diminish the number of both.

AN ESSAY, &c.

HOWEVER easy the act of Childbearingmay be among savage tribes and certainindi-viduals in various states of society, we find it

among others an operation of great pain andfrequent danger. It is not intended here to in-quire minutely into the causes of the depar-ture of this act from its original simplicity,

but merely to glance at some of the most evib

dent; among which we must regard civiliza-

tion and refinement as the most prominent,

if not exclusively the only ones. It is not

compatible with my present purpose, to point

out in what manner these causes have operat-

ed to effect this change; I shall therefore only

state, a change has been produced in the fe-B

t

male human system, which subjects it to pain

and difficulty in parturition; to show in what

some of these changes consist, and how to

ameliorate them, is more especially the object

of the present essay.

The causes of difficult and painful labours

are various, and may with great propriety bedivided into two general heads; namely, thosewhich arise from some imperfection of the

Pelvis, and into such as may tendl to interruptthe natural and healthy functions of the softparts; the latter however only comes withinour present notice. The soft parts concerned

in labour, are those which are directly, andthose that are indirectly employed ;-the

former are the uterus, vagina, perimeum; thelatter, the abdominal muscles, those of thethorax, diaphragm, bc.

A short anatomical description of the Ute-rus, with some physiological remarks, are judg-ed necessary, that some of the opinions ad-vanced may be the better understood.

Ii

The Uterus is a hollow viscus, in which the

great object of conception is perfected. From

the phenomena of Labour, and by actual dis-

section in the gravid state, we do not hesitate

to say it is composed chiefly of muscular

fibres and blood-vessels. Although it be ad-

mitted on all hands that it possesses muscular

fibres, yet anatomists are not so well agreed

as to the manner in which they are distribut-

ed. Dr. William Hunter, in his plates of the

gravid uterus, delineates them as transverse

in the body, but, as describing at the fundus,

concentric circles round each orifice of the

Fallopian tubes; therefore, according to him,

there are two orbicular muscles, and a trans-

verse one. Malpighi describes them as form-

ing a net work, while Ruysch contends they

appear in concentric planes at the fundus,

forming an orbicular muscle.*

This diversity of description proves, that

* Mr. Charles Bell has attempted to elucidate this obscuresubject, but with as little success as his predecessors.

the distribution of muscular fibres in the ute-

rus has never been satisfactorily traced, and

that their accounts have been very much in-fluenced by the individual theory of these

great men. Great patience has been exercis-

ed, and much labour expended in these re-searches, by very many excellent anatomists,

besides those just named, yet they have never

been able with their knife to clear up this

point; we must therefore have recourse to

other means to satisfy ourselves; the only

certain one it appears to me is, to deduce

them from the action of the uterus itself; this

at least warrants two distinct sets, the one

circular, the other longitudinal. The circular

fibres are those which run in the direction of

the transverse diameter of the uterus; they

most probably commence at the fundus, and

terminate at the extremity of the os tlne.

They act somewhat like a sphincter muscle,

and are, as we shall prove by and by, inferior

in strength to the longitudinal fibres, which

are those running in the perpendicular direc-

tion of the uterus; that is,i lines more orless direct from the .. s40 the terminationof the neck; they saeve to diminish the lengthof the teZ s.*

The uterus is usually divided into fundu,body, and neck. The fundusi made to cor-preh d all that portion which is above the

tion of the Fallopian tubes; the body, thatportion below the tubes, but superior to theneck; the neck that part which pendantfrom the body, and terminated by the otinc. This viscus is abundantly supplied withblood~.vesels, which very frequently anasto~mose; o much so, that when injected in theimpregnated state, they appear scarcely anything else. These vessels however are verydifferent in size in different states of thewomb; in the unimpregnated state they are

'the uterus may have fibres running in very many moredirections than the two just mentioned, but the two noticedwill serve to explain the phenomena of labour sufficiently,without having recourse to them.

small, and much convoluted, though numer-

ous; but in the impregnated state they are

much enlarged, and become much straighter

in their course.

The veins are much larger than the arte-

ries; they very frequently anastomose; are

without valves, and terminate on, or expand

into sinuses of sufficient size, in some in-

stances, to admit the extremity of the finger.

It has been usual to consider the fundus, bo-

dy, and neck, of the uterus as a single viscus,

whose actions were similar and dependent on

each other; I have my doubts of the proprie.

ty of this combination, as it does not accord

with many circumstances connected with this

organ. Hitherto the physiology of the uterus

has been but too carelessly considered; re-gard having chiefly been paid to the conse-

quences of its action, rather than the mode

in which these actions were performed.

I do not flatter myself I have completely

15

and satisfactorily explained the various finc-tions of this organ; but I hope to awaken at-

tention to this subject in others, whose talents

and leisure will better fit them for the inves-tigation. What will be advanced on this head,

is offered with diffidence, conscious of the dif.

ficulty that attends enquiries of this kind, and

the impossibility of reducing speculation tomathematical demonstration. The office of the

body and fundus, is diametrically opposite to

that of the neck or mouth of the uterus in

time of labour; while it is the duty of the

former to contract, it is that of the latter torelax; and on the more or less perfect estab-

lishment of these different actions, other thingsbeing equal, depend the facility, or difficulty

of labour.

Before we proceed farther, let us inquireinto the functions of these parts. From re-viewing the various changes which take placein the uterus from the time of impregnation.to the expulsion of the mass it has been mar

t6

turing, we cannot fail being struck with thevarious resources it seems to possess, and the

wonderful order it pursues, to give the greatest

possible chance of perfection to the ovum;to secue it against accident; and finally, to

cast it off when it can no longer be useful to

it.

The various changes which the womb un-

dergoes in these several processes, have been

pretty distinctly marked, and the various phe-

nomena of labour pretty faithfully recorded;

but we have yet to lament, that so little pro-

gress has been made in the knowledge of re-

medies to prevent or overcome the difficulties

which but too frequently occur in the different

stages of gestation, and parturition: this can

only be acquired by a more minute investiga-

tion of the laws of nature, and an attention to

the influence of certain agents acting on the

female constitution in general, but more par-ticularly on the uterine system, and especially,

on the different parts of the uterus itself To

17

believe in the influence of certain causes onthe different parts of the uterus, may at firstsight appear unphilosophical; and to supposewe shall ever have them under subjection,will be considered as Utopian; but notwith-standing this, I have no hesitation in believingthat the time will arrive, when we shall beable to prescribe internal remedies with asmuch certainty for a preternatural rigidity ofthe neck of the uterus, and for a too feebleor too powerful contraction of its fundus andbody, as we do now for an intermittent.* ForI cannot help regarding the neck of the uterusas a distinct and independent part from thebody and fundus, and as having its own pecu-liar laws and actions; and that this separationof powers, is absolutely necessary to the ex-planation of some of the phenomena exhibit-

* A part of this conjecture has since been verified, by ourknowledge of the use of the Ergot, of which we shall speakmore by and by; indeed the influence of blood-letting wherethe neck of the uterus is preternaturally rigid, corroboratesanother part.

18

ed by health and disease, and the influence ofcertain agents on these parts.

My reasons for thinking so are, first, thatwe find the fundus and body may be distend-ed to a great extent without affecting the ar-rangement of the neck; thus in every uterinepregnancy we see these parts gradually yield-ing to the influence of the ovum, until aboutthe sixth or seventh month; while the neckremains very much the same as before im-pregnation.

Secondly, that after the sixth or seventhmonth the neck undergoes its changes, whilethe fundus and body become in a great mea-sure stationary; so that two distinct processes,or rather the same process is performed attwo different periods, and in different parts,in the order we have just mentioned.

Thirdly, that the neck may be affected bydisease, while the fundus and body may re-

19

main free, and the reverse; and the neck may

contract, or relax, while the other parts are in

opposite states: thus in women who are in

the habit of aborting from some peculiarity

of the uterus, we find that the body and fundus

may be excited into action while the neck for

a long time remains passive; and also, the

neck may relax, and the body and fundus after

some time may be excited to contraction.

And in cases of atony of the uterus after a too

sudden delivery, the body and fundus may

contract while the neck is the only part in

fault, and vice versa.

The different conditions that the parts of

the uterus may be in at the same time, where

atony partially prevails, would seem to de-

monstrate the truth of what is here advanced.

It is a fact well known to almost every prac-

titioner of midwifery, that each of the parts

into which we have divided this viscus, may

separately and independently of each other

be in a state of contraction or of relaxation.

20

and thus exhibit different phenomena and beproductive of different results.

Now were these parts not influenced bydifferent circumstances, these things could nothappen; since two distinct actions ae goingon at one and the same time; or one of theseparts may be labouring under disease withoutinvolving the other.

That a woman may carry her child to thefull period allotted for its perfection (and thatshe may afterwards produce it with the leastpossible trouble) a number of circumstances

must concur with the greatest possible regu-larity. That she may carry it to the full periodof gestation, she must be exempt from all andevery cause capable of exciting uterine con-traction; or at least that degree of it whichwould, sooner or later, terminate in delivery ;*

* Mr. Burns is of opinion that when the uterus is once ex-cited to action, we cannot arrest it; than which, nothing isfarther from the fact, and is of course mischievous in itstendency, as it may prevent the use of proper remedies.

21

and that delivery may be then effected with

the greatest facility, the following circum-

stances must obtain:

First, there must be a subsiding of the ab-

dominal tumour, and if at this time a finger

be introduced through the os tinea, we shall

find the membranes alternately tense and re-

laxed; these circumstances are owing to the

uterus now beginning to contract, and forcing

the presenting part into the pelvis.

Secondly, there must be a secretion of mucus

from the vagina: in some instances this flows

from it, several days previous to the onset of

pains; but for the most part it only happens a

few hours before they are felt. This mucus is

secreted from the surface of the vagina, and

perhaps from a portion of the neck of the

uterus. Why these glands are excited to this

duty may perhaps be difficult to explain, but

their action appears intimately connected with

a certain state, or condition of the os tineae;

22

thus we find, ceteris paribus, this secretion to

be most abundant, where there is the great-

est disposition in the mouth of the uterus.to

dilate or relax; and with this, is connected,

the same disposition of the perineum. It must

be observed, that the secretion here spoken

of must not be confounded with leucorrhoea,

as this discharge is by no means favourable

to this effect.

Thirdly, the mouth of the uterus must

yield easily, that the contractions of the body

and fundus may not be exerted for too long a

time unavailingly. The dilatation of the mouth

of the uterus, when best performed, is either

before or very quickly after the painful con-

tractions of the uterus have taken place; this

in general is done without the mechanical

aid of the contents of the uterus.

Fourthly, the body and fmundus must con-

tract with sufficient force, to make the child

pays through the pelvis.

28

Fifthly, the perineum must unfold without

much or any mechanical force, that the child

may not be detained in passing through the

os externum.

Sixthly, there must obtain between the foetus

and pelvis, a proper proportion, and the

former must be well situated, that it may de-

rive every advantage from the circumstances

just enumerated.

Having thus pointed out what ought to

obtain, that labour may be short and easy, we

shall proceed to investigate some of these

phenomena: and first that of the

Dilatation of the mouth of the Uterus.

It is a fact very well known to accoucheurs,

that some time before the period of labour,

the mouth of the uterus is a little way opened :

this does not universally obtain, though suffi-

24

ciently often to warrant the assertion, that itdoes for the most part. This first degree ofdilatation, however, is by no means essentialto a speedy delivery, since it is generally ac-companied with very firm and unyielding

edges; this obliges us to enquire whether this

state be the effect of a mechanical, or of what

other power. In order to which, we shall re-

mark, that there are two states of the os

tincae at this period; the one, as just mention-

ed, attended by very resisting edges, and the

other with soft and yielding ones; these are

essentially different. In the former case, it

must be regarded as the effect of the mechani-

cal stretching of the uterus, the fibres of the

neck of which have been sufficiently unfold-

ed to widen this aperture so as to admit the

extremity of the finger, or even a larger body;

the uterus appearing, as it were, not to have

sufficient substance to cover the ovum com-

pletely. But this, in some other instances, may

arise from another cause: thus, when the

uterus is not so fully distended, we may also

25

pass the finger; but in this case it is owing to

the neck and mouth never being so complete-

ly shut after the first child, as in the virgin

state; therefore this case can only happen

where the uterus has been subjected to the

influence of labour.before.

In the other case, we have mentioned the

mouth of the uterus to be in a very different

state; that is, its edges are pliant, and may by

a very gentle force be eldarged. This depends

on a very different cause, and must be regard-

ed as a salutary step towards labour.

Baudelocque* appears to look upon both

these states as the effect of the same cause;

for he observes that, "the orifice of the uterus

"is almost always a little openi before the

"epoch of labour. We see the reason of this,

"by following, step by step, the order of the

"development of that viscus, and by attend-

* Vol. 1. p. 3S6. Heath's Trans.

D

26

" ing to all that passes at its orifice in the'lat-

" ter periods of gestation."

In this paragraph he alludes to an explana.

tion he has previously given, in which he en.

deavours to explain the successive develop-

ment of the uterus, and eventually the open-

ing of its mouth at the time of labour; we shall

therefore transcribe it, that our quotation may

be the better understood. He observes, page

182, par. 199 and following, that "the fibres

" of the fundus and body of this organ, are

" more supple, and naturally more disposed to

"unfold, than those of its neck, furnish almost

" the whole of the amplification necessary be-

"fore the sixth month of pregnancy; so that

"till that time the uterus seems to borrow

"nothing from its neck. It is at this epoch

"that the fibres of the latter part begin to de-" velop, a nd contribute with the former to

"the dilatation necessary f~r the convenient" lodgment of the fretus and its appurtenan.-

"ces. From this time all the fibres extend

27

"and unfold in the same proportions and con,

" tinue to do so for some time but towards"the end of pregnancy, the dilatation of the"uterus is made almost entirely at the ex-

" pense of the fibres of its neck; because"those of the fundus make a greater resist-" ance; and there no longer exists a perfect"equilibrium in the re-action of those two"parts, either on each other, or on the pro-" duce of conception.

"As soon as that equilibrium is destroyed;"the fibres of the bod, and especially those"of the fundus of the uterus, begin to make" eflhrts to expel the substances which Consti-r"tute the pregnancy, and do it in a manner

"sensible to the touch. If w then introduce"the finger through the orifice of the uterus,"so as to touch the membranes of the foetus,"we find them flaccid one moment, and tense"the next; which clearly demonstrates this:alternate action."

28

" At this time the fibres of the neck of the" uterus sustain not only the whole effort of"the internal agents, which they participated"before with those of the fundus, but also the" effect of the re-action of the latter on those"same agents; which constrains them to un-"fold so rapidly, that in less than two months"the neck is developed, and entirely effaced.

" If the cavity of the uterus becomes still"larger after this period, it is all at the ex."pense of these fibres, now become weaker."At first they distend and lengthen, then"they seem to range themselves by the side"of each other; which renders the uterus so"thin in this part, that the edges of its orifice"are often no thicker than two or three folds

' of common paper.

"It is by the same mechanism, that the di-"latation of the orifice of the uterus begins to

be effected, and labour pains manifested. Ifthe end of the ninth month of gestation is

29

" almost always the epoch of those pains, it is" because the order of the successive develop-" ment of the different parts of the uterus, as" I have stated it, is almost immutable.

" The cause of this first degree of dilatation" being well known, must throw the greatest" light upon that which takes place in time of" labour; and shows us it is not immediately" and entirely the effect of that species of" wedge which the substances subjected to" the contractions of the uterus present to" its orifice."*

From this it would appear that the openingof the mouth of the uterus at the commence-ment of labour, and also that degree of open-ing which exists long before this period, is theeffect of the same cause; namely, the influ-ence of the body and fundus mechanicallyacting upon the orifice of the womb. But thiscannot be the case for the reason just stated;

* Ibid. Vol. 1. p. 336.

80

namely, that the degree of opening may be

the same, but the resistance of the edges of the

mouth is very different; in the one case the

circular fibres of the neck obstinately maintain

their contraction; whereas in the other, they

are in a greater or less degree relaxed; and

that this relaxation is not the effect of this

uterine effort acting mechanically is evident,

since we find it existingwhere there is no

portion of the ovum made to engage in it,

consequently cannot act like a wedge. Besides

were it owing to this cause, it would appear

like a part that was yielding to a mechanical

impulse, and would consequently exhibit

marks of resistance; that is, it would still main-

tain the action of contraction, and not that of

relaxation. Indeed Baudelocque himself seems

aware of this objection, for he observes, page

887, par. 616, "Although in many cases,

"where the waters drain off prematurely, no

" part of the child can engage in the orifice

"of the uterus, yet it does not fail to open, in

" the same manner as if the bag formed by the

" protrusion of the membranes were entire;"from whence we see that the action of that"organ is alone sufficient to effect the dila-" tion of its neck. But it will perform it so" much the more easily, as the uterus is more" distended, and as the body it contains is" more solid."

Here he appears to abandon, in a great de-gree, his mechanical doctrine, and to confessthe action of the uterus alone to be suffitientto effect the dilatation of its neck; but hedoes not pretend to determine what that ac-tion is; he conjectures in the next paragraph,that the soft and gradual pressure of the dis-tended membranes may have an influence onit; for "Independently," says he, "of the force"which the membranes distended by the wa." ters exert in the orifice, when they can en-"gage in it like a wedge, the soft and gradual" pressure which they continually exert on all" the neighbouring parts, determines a reple-" tion in them, which favours their develop-

32

" ment and renders it less painful." But

unfortunately for this conjecture, should this

determination take place, it would have a

diametrically opposite effect; for the moreturgid or engorged with blood the neck

should become, the less disposed would it he

to dilate. Of this we have abundant proof,

when this part becomes inflamed.*

Besides, the uterus in many instances di-

lates as kindly after the evacuation of the wa-

ters as before; of this the following history is

a proof:

Mrs. is always surprised by a dis-

charge of the waters without any pain; but

this so quickly succeeds, and the child so sud-

denly expelled, that her nearest neighbour

SIt must, however, be admitted that during labour, or evenbefore, there is some increase of determination to these

parts, as there is an increase of action in their vessels, as wecan sometimes determine by the touch; but this is never in-strumental to dilatation.

88

eannot get to her before it happens. This has

obtained with all but her first labour.

Were it necessary, we might multiply au-

thorities to a great extent, to dip aethismechanical doctrine; bat sha only give one,Dr. Denman, vol. II. page 37. "More than"one case," says the Doctor, "has occurred

"in my own practice, to which particular at-"tention has been paid, for the purpose of" registering the observation, in which the"labour has commenced properly, and pro.." ceeded with much activity till the os uteri"was fully dilated, and then ceased altogether

"for several days : at the end of that time the"membranes breaking, the action of the ute-" rus ha retutned and the labour been finish-"ed speedily, with perfect safety t mother"and child." Here we see the dilatation ef-fece without the wedge-like influence of themembranes or child.

From what has ben said, we trust it wil

84

appear that, in the most natural and favoura-ble cases of labour, the mechanical power ofthe ovum has no influence in dilating themouth of the uterus. It must, however, be ad-mitted there are many instances where thecontrary obtains; thus we see cases where theaction of the uterus is so rapid and powerful,that the child is forced through the orificewith great violence, and risk of lacerating it;but in these instances the mouth of the uterusexhibits a very different appearance from thatwhere the dilatation is effected by a differentagent. When the head, or presenting part, ismade to force its way, the mouth of the ute-rus transmits it with great reluctance, andevident hazard; for it pertinaciously resists, asis evident to the touch; while on the contrarywhen it has dilated, agreeably to the laws ofnature, it yields most willingly. It has mostprobably been owing to a proper distinctionnot being made between these cases, that themechanical account of the dilatation of themouth of the uterus has so universally pre-

85

vailed; but there is scarce a writer on thissubject who does not furnish facts to disprovehis own doctrine on this head.

The cases just mentioned are to be lookedupon as departures from the healthy and ordi-nary progress of labour; and are thereforenot to be considered as militating against the

doctrine we wish to establish. It may be ask-ed, how it comes to pass, if the membranes

distended with their water are of so little

consequence to the opening of the mouth of

the uterus, that a painful and tedious labour

most frequently follows where they have beer

prematurely ruptured? The answer we con-

ceive to be easy. In those cases where the

membranes are ruptured some time before

the legitimate pains of labour have commen-

ced, the uterus is oftentimes thrown suddenly

into contraction, and this before it is prepar-

ed, (if we may so express it) for the regular

routine of parturition; consequently the neck

is not in a disposition to dilate; not because it

86

fails in assistance from the membranes, but

because all the preparatie conditions are not

complied with; therefore not properly pre.

pared to perform all its duties. But it is by no

means an invariable thing for a l1r to be

tedious after this early escape of the watr~;unless indeed we date the commencement

of the labour from this event; in this case

the labour might, with strict propriety, be

said to be tedious; as twenty-four, thirty-six,

eight and forty hours, nay in some instances,

a much longer period has intervened before

the delivery was effected: we may therefore

safely, we believe, lay it down as a rule, that

a more tedious and painful labour does not

ensue from the premature rupture of the

membranes, unless the uterus is thereby im-

mediately thrown into contractions; but shoultdd

no pain succeed for some time, the labour will

be, cateris paribus, as in ordinary.

After having endeavoured to show in what

manner the mouth of the uterus is not dilat-

ST

ed, it may be considered incumbent me topoint out in what way, our opinion, this ef-fect is produced. This is confessedly a difficlty of some moment, but it must be at-

tempted; and should we fail to be satisfactory

on this head, we shall experience but the fateof all who have gone before us. We trust,

however, it will appear subject to certainlaws, whose ultimate eect we have in ourpower to imitate; and this should be regard-ed as a matter of some consequence. But be-

fore we proceed farther with this subject,must stop to inquire into

The different kinds of contractions of the

Uterus.

First, The longitudinal contraction :t4his

iperformed by the fibres of the uterus, socalled, or those fibres which run from thefunodus to the neck; it seues to shorten theuterus in the direction of these fibres ; conse-quently to expose it8 contents more and more

88

by making them approximate the mouth; and

this will be in proportion to the diminution

of resistance at this part, and the force with

which these fibres may act.

The circular contraction:--this action is

performed by the fibres so named; they, as it

were, run round the uterus, commencing at

the fundus, and terminating in the circle form-

ing the neck: they tend to diminish the capa-

city of the uterus in the direction of its trans-

verse diameter, consequently have little or no

immediate agency in expelling its contents.

The simple contraction:---or when either

of these sets of fibres act separately, as before

labour more especially, when the finger is in-

troduced through the os tincae, we find the

membranes alternately tense and relaxed: in

this case we presume the longitudinal fibres

act alone, as there is no stiffening of the circle

forming the mouth; or as when the waters

have been evacuated, the uterus is made to

89

embrace its contents, and no pain for a longtime is produced; we suppose in this instance,the circular fibres act alone, as there is no ef-fort to expel the contents of the uterus, whichwould not be the case did the longitudinalfibres co-operate with them.

Compound contraction :-or when both setsof fibres act; their united action is proved,we conceive, when there is a hardening of themouth of the uterus, and an evident depres.sion of this viscus with its contents into thelower part of the pelvis.

Tonic contraction :---by this we understandthat uniform action which the uterus exertsto reduce itself to its original size; this ap-pears to be the effect of all the fibres foldingthemselves up after the distracting cause isremoved.

The spasmodic, or that contraction of theuterus which is for the most part accompani-

40

ed with pain. It must be remembered, however,that pain does not necessarily belong to thisspecies of contraction, since some women aredelivered without it. We should, therefore,agreeably to this fact, rather call this speciesthe alternate contraction of the uterus, as ithas a greater or less interval between eachcontraction: when this action is best perform-ed, it is, we presume, chiefly by the longitudi-nal fibres.

It may here become a question, how are thefibres of the uterus enabled to perform thisalternate contraction? Since we know that amuscle after having contracted, cannot repeatthat contraction without being first relaxedand then elongated. Where resides this elon.

gating power in the uterus? This enquiry, sofar as I know, has never been made, but the

necessity of determining it will immediatelypresent itself, when the question is asked. Tosolve it, no doubt, is difficult, perhaps impos-

sible, with our present imperfect knowledge

41

of the anatomy and physiology of this impor-

t ant viscus; but is it not justifiable, under such

circumstances, to hazard a conjecture, how-

ever small its approach may be to truth? If

this be the case, and we are allowed to urge

a crude opinion, we would say, we must look

for this power in the blood-vessels and sinuses

of the uterus.

The first change the uterus suffers from im-

pregnation is distention; the next, that of con-

traction. The uterus is then put in a state of

elongation by the powers within it, which,

when it suffers to a certain degree, contracts;

what is the effect of this contraction? It ap-

proximates its fibres; it expels a considerable

quantity of blood from its sinuses and larger

blood-vessels, into the general system of the

mother; it diminishes the size of its blood-

vessels; it makes them become more convolut-

ed; the uterus becomes paler, a proof of a

lessened quantity of blood: the face of the

woman becomes suffused, nay sometimes livid.F

To facilitate the departure of blood from

the uterus during its contraction, the veins are

not furnished with valves,* by which means

* That this is the true reason why the veins of the uterus

are not furnished with valves, is rendered more than proba-

ble by the following case, from the fourth volume of Medical

Essays and Observations, p. 355, by Mr. John Paisley.

"Upon the 9th of June, 1730, I was called to a woman in

labour, about a middle age, of a low stature, and pretty fat,

who had born several children; and found her in an exceeding

low condition, with cold sweats, and severe faintings; her

extremities cold, without any pulse, and unable to utter a

single word, though she showed some signs of her being de-

sirous to speak with me. The midwife that attended her, had

gone off upon my being sent for, and left a young practitioner,

whom she was training up in that business, who gave me the

following account of the poor woman's case, viz: That she

had been several days in labour, and that all along the mid-

wife imagined affairs were in a very good way, and the child,

as she thought, in a very right posture; though after the waters

broke, the child's head had never advanced by the strongest

pains. From the first day the woman passed no water; on the

fifth the midwife sent for some stimulating medicine to pro-

cure the discharge-this had no effect; another still stronger

was sent for, with like want of success. In this state things

remained until the sixth day at midnight, when I was sent for.

I found her in the situation just described. It was evident

when matters were brought to this pass, that the poor woman

had not so much strength left her, as to bear the fatigue of

being put into a posture for being delivered, and that it was

impossible to afford her any relief. She died in a few minutes.Next

48

the blood is allowed to pass freely in the di-

rection of any given impulse. What is the ef-

fect of the subsequent relaxation? The fibresbecome longer, straighter, and more easilydistensible; the sinuses and large vessels are

less compressed, and transmit more blood ina given time; the face of the woman becomes

paler; the uterus becomes again pretty sud-

Next day I prevailed with the firiends to have her opened,and after I had cut the teguments and laid them back, I wassurprised to meet with a black membranous body like coagu-lated blood (which in reality it was,) covering all the forepart of the uterus, though distended so much with the child.This I easily separated in one cake from the uterus, and

when it was upon the table, it was about a foot and a quarterlong, a foot broad, and a quarter of an inch thick. Whetherthis proceeded from the oozing out of blood from the sub.stance of the uterus, by the strong pressure when the painswere violent, or some other part of the abdomen, I do not de-termine, for I could not observe the least appearance of anyraptured vessels in either, after the most accurate search Icould make; nor was there one drop of blood in any otherpart of the abdomen."

In this case we imagine that some interruption was givento the equal flow of the blood during the contractions of theuterus, and that the vessels suffered some small rupturesthough the apertures were not visible; and we believe thatthis would always take place were the veins furnished withvalves.

44

denly charged with blood, as is evidenced by

its deeper colour; its fibres are distracted or

elongated by this influx of blood, and hence

are enabled to contract.

It may be urged against this opinion, that

the uterus contracts for the most part more

frequently, and more powerfully, as its sub-

stance becomes increased in density,--as to-

wards the close of labour; consequently the

influx of blood must be much retarded, and

of course its impetus or quantity insufficient

to elongate the fibres sufficiently to allow of

a new contraction. But in answer to this we

must observe, that at this period of labour

the circulation is very much increased, and

although the absolute quantity in the uterus

may be diminished, the velocity is very much

augmented; and added to this, its irritability

is much increased, therefore, less distention

will be required. It may also be said, there are

instances of the uterus ceasing to act for a

45

considerable time, and where we must supposethe circulation to go on in it. That the uterusin some cases will cease to act, is most true;but this by no means destroys the suppositionwe have been making,-as this part, like allothers, may have its fibres in a condition inwhich they will not obey their ordinary stimuli-- it may proceed from exhaustion, or fromlocal plethora; stimuli will cure in the oneinstance, and blood-letting in the other.

The irr'egular contraction :--or when a partof any set of fibres act; as in cases of what iscalled spurious pains.

Having thus noticed in a general way thevarious actions of which the uterus is capable,we shall proceed to enquire into

46

The Relative Strength of the different Sets of

Fibres.

We have already observed that the longitu-

dinal fibres were stronger than the circular;our reasons for thinking so, are,

First, that were they of equal strength in

all parts of the uterus, delivery could not

take place, since the circular fibres would em-

brace the body of the child, and thus retain

it; their action being, as we have already said,

to diminish the uterus only in its transverse

diameter, consequently is at right angles with

the longitudinal.

Secondly, that when, from any circumstance,

the power of the circular fibres is increased,

either absolutely or relatively, there the la-

bour does not advance; therefore the circular

fibres are not to be considered as directly in-

strumental in expelling the child.

47

Thirdly, as the circular fibres, from the di-

rection of their action, do not immediatelycontribute to the advancement of the child,they must be considered as the weakest set,-- since delivery takes place without their di-rect aid; the longitudinal fibres have then notonly to move the child, but overcome theirresistance.*

Now let us apply these facts to the expla-nation of the dilatation of the uterus and theprogress of labour.

When the woman has carried her child tothe full time of gestation, that process termedlabour must ensue, that she may be enabledto part with it; for this purpose, one part of

the uterus must yield or dilate, while another

* This is particularly the case in the instances where themembranes are prematurely ruptured; the uterus, by virtueof its tonic contraction, accommodates itself to the variousinequalities presented by the child's body, and some of theseare eminently calculated to retard labour; yet the longitudi-nal fibres overcome them.

48

must contract. The uterus is closed at bot-

tom, and maintained in that situation by thecontraction of the muscular fibres of its

mouth, but these must relax that the child

may effect its escape. We must therefore re-gard the circular and longitudinal planes offibres, as a kind of antagonist muscles to each

other. The longitudinal fibres yield more wil-

lingly to impulse from within the uterus than

the circular during gestation; owing perhaps

to their greater length, or perhaps greater

laxity ;* they continue to yield until they are

so much upon the stretch as to induce a dis-

position to contract; this they eventually do.

The circular fibres on the other hand, from

their greater rigidity, most probably are put

immediately upon the stretch; they therefore

have a constant stimulus to excite their con-

traction; hence the mouth of the uterus keep-

ing closed. But so soon as the longitudinal

fibres becomes uneasy, from distention, they

SHence perhaps the lengthened form of the uterus.

49

become refractory and will yield no more

without resistance; they then contract, and

continue to do so until the stimulus of disten-

tion becomes still more powerful, which

eventually brings on the period of labour. By

the contraction of the longitudinal fibres, the

length of the uterus diminishes; this puts the

circular upon the stretch, since the uterus can-

not diminish in one direction, while the mouth

of the uterus remains shut, without augment-

ing in another, therefore the circular fibres

are a little distracted, and they immediately

co-operate with the longitudinal, and force the

uterus with its contents lower into the pelvis;

in this instance, what we have termed the

compound action of the fibres, takes place;

this is proved by the edges of the mouth of

the uterus stiffening during the contraction.

This kind of action is reciprocated for some

time; but the circular fibres eventually yield

to the influence of the longitudinal; first, from

their having expended a portion of their pow-

O

50

er in maintaining a state of contraction solong; and secondly, their being absolutely theweaker fibre; hence the circular fibres whichconstitute the neck, relax; and hence the di-latation of the mouth of the uterus.

It may be asked, if the contraction of thelongitudinal fibres prove a stimulus to the cir-cular, how does it happen while the mem-branes remain entire, that they do not con-tinue this contraction until the membranesare ruptured, or even longer, since the stimu.lus of distention must be applied, as often asthe longitudinal fibres continue to contract?To this we would answer, that; when thesefibres are acting properly, the longitudinal aregradually getting the ascendancy of the circu-lar, or in other words, the circular contractless forcibly; in consequence of which, themouth of the uterus becomes more dilated,which allows the membranes to be pusheddown during the contraction, as the liquoramnii will naturally be focel to that part

5t

which gives the least resistance to its escape,

and of course the uterus will be less distendedtransversely, and the circular fibres be put less

upon the stretch; or what is the same thing,

less stimulated; then as they are less stimulat-

ed, by the uterus having more room for the

disposition of its contents, they will contract

less forcibly; and this diminution of force, in

contraction, enables the membranes to pro-

trude still farther, which again has its effects

in lessening their contraction, by offering still

more room for the waters to retire in, during

the contraction of the other fibres, and even-

tually they cease to act.

Secretion of Mucus and yielding of the External

Parts.

During labour, and even before, in some in-

stances, there is a considerable discharge of

mucus from the neck of the uterus, and va-

gina, which is extremely favourable to the

52

dilatation of the external parts. Previous to

labour, and more especially during it, there is

a more than ordinary determination of blood

to these parts, which, when not excessive,

stimulate the glands here situated, to an in-

crease of action; hence the abundant flow of

mucus. This mucus is sometimes tinged with

blood, which arises from the rupture of some

of the small vessels of the chorion, or perhaps

placenta.

This mucus seems to serve a double pur-

pose ;--first, it lubricates the passage, and bythat means allows the child to pass more

easily; and secondly, it facilitates the relaxa-

tion of the vagina and perimeum, by diminish-

ing the quantity of fluids sent to these parts du-

ring this period; and thus acts like topical de-

pletion, which we well know, favours relaxa-

tion; this we are inclined to believe is the chief

use of this discharge. Were it merely to lubri-

cate the passage, we could always obtain the

same end by artificial means; but every body

58

knows this does not answer the purposeequally well. This fact is tacitly implied, ifnot acknowledged, by every writer on thesubject of midwifery, when they cautionagainst frequent touching lest you waste thenatural mucus of the part; why this caution,if it were merely to moisten, since we have anumber of substitutes? No, the fact is, frequenttouching stimulates these glands beyond thesecreting degree, therefore the parts becomedry, for want of it; and rigid, because theparts have failed in this depletion. This is thetrue principle on which we should cautionagainst indiscriminate touching.*

* It may be supposed that the quantity of mucus discharg.ed during this period is not sufficient to produce the endcontended for, since the amount thrown off would rarelyperhaps exceed two or three ounces. This objection is morespecious than solid, since we cannot always estimate the re-laxing or debilitating effect by the quantity of the fluid dis-charged; for instance, the relaxation and debility that attendthe seminal discharge could by no means be anticipated froma mere view of its quantity.

Of the Contraction of the Fundus and Body ofthe Uterus.

That the uterus may be enabled to expelits contents, as we have already said, the fundusand body must contract, while the mouthmust relax. We have endeavoured to showhow the latter was effected; let us now for amoment attend to what must be done by thefundus and body, that delivery may take place.

When the mouth of the uterus is sufficient-ly dilated to allow the child to pass throughit, the fundus and body must continue to con-tract; this contraction is of two kinds, namely,the tonic, and the spasmodic or alternate.The tonic contraction is chiefly performed bythe circular fibres; by this contraction, thewhole of the internal surface of the uterus is

applied to the body to be moved, and the lon-gitudinal fibres by this means are broughtmore closely into contact with it, and of courseare enabled to act with more effect; this per-

55

haps is the chief use of the circular fibres athis period of labour, as they do not, in anyinstance, directly contribute to the advance-ment of the child, as we have already observ-ed, and shall now endeavour to prove morefully.

We shall relate some circumstances attend-ing the contraction of the uterus which willdeserve notice, and to the truth of which everyaccoucheur will bear testimony.

First, that a considerable degree of contrac-tion may take place in the circular fibres with-out producing pain; thus, after the evacuationof the waters, and the uterus is closely appliedto the body of the child, even to a degree thatwould render turning impracticable---yet nopain is felt.

Secondly, when this contraction is violent,it throws the uterus into inequalities, and some-times divides it like an hour glass; this obtains

56

in a degree before the birth of the child, butmore especially after it, and before the expul-sion of the placenta. In these instances, thecontraction is obstinately maintained, but nopain is felt.

Thirdly, if the finger be applied to the pre-senting part, during the continuance of thiscontraction, it is not found to advance.

Fourthly, when this constriction is mostviolent, the longitudinal fibres act, for the mostpart, with more force; since they are not onlyobliged to effect the delivery, but also to over-come this additional resistance; another proofof their superior strength.

Fifthly, this stricture continues without anyintermission, as far as we can determine, forhours; but this does not suspend the painfuland alternate contractions of the other fibres;nor does this constriction relax during thisalternate contraction; therefore, much time is

57

lost and much pain endured from this circum-

stance; it however yields eventually, and fromthe same cause, and in the same manner as

the mouth of the uterus does at the com-

mencement of labour.

Sixthly, when the painful contractions take

place, the presenting part is pushed lower

into the pelvis; but when this ceases, it most

frequently recedes a little.

From these facts, the following inferences,we think, are deducible.

First, that the drcular fibres may contract

to almost any degree, without being attended

with pain.

Secondly, that their contraction alone,however violent, does not forward the child.

Thirdly, that they do not possess the powerof alternate contraction in the same degree a

H

58

the longitudinal fibres; and that they may

exert this power; it is necessary at first to

have them distracted by some force or other.

Fourthly, that the pain felt during labour,

must in a great measure, if not entirely, de-

pend upon the contraction of the longitudinal

fibres.

Fifthly, that the changes the uterus has suf-

fered from civilization and refinement, must

be chiefly confined to its longitudinal fibres.

From what has been said then, the spas-

modic or alternate contraction of the uterus

appears to be nothing more than an increased

effort it makes to overcome the obstacles op-

posed to its progress to a state of vacuity; and

that the pain attending these contractions de-

pend upon certain physical changes which the

longitudinal fibres have undergone from the

causes just mentioned. Why a particular set,

or given direction of fibres should have suf-

59

fered more than another, may be impossibleto determine; but that they have, we believeto be most certain. This change, however, isby no means confined to the uterus, as everystraight muscle of the body appears to haveparticipated with it, since it is admitted that theman of the civilized world has lost much ofhis original strength. On the other hand thecircular muscles, as far as we can determine,have lost nothing of their primitive power;since it is more than probable, that the vari-ous sphincters,* among which we may reckonthe circular fibres of the mouth of the uterus,perform their duty as effectually and as pow-erfully, as in the time of our first parents.

Do not these facts emphatically accountfor women who have suffered these changes,having more tedious and painful labours, thanthose who have not undergone them,-as thewomen of savage nations, the women of Ca-

The heart, or intestines, may also be included.

60

labria, Vc.; and without the necessity of hav-ing recourse to a physical necessity, derivedfrom the erect position of man, or the pecu-liar construction of the pelvis?*

The different actions we have assigned theuterus, must not be considered as exclusively

belonging to woman;---as the brute, doubt.less, has the same. It isndeed true that the

labours of the brute are not generally attend.ed with pain or difficulty, and this is urgedagainst the idea of pain being of artificialorigin, as they have also undergone greatchanges; but it must be remembered they havenot suffered the same revolutions as man, orat least not in equal extent; but that the samegeneral phenomena, progress, and casualtiesattend them, as occur to the human female,is most certain; and when causes occur, ca-pable of diverting their labours from theirusual healthy course, the same difficulties

* See Osborne's Essays; also Med. Mus. vol. i. p. 27O

O6

take place, and are attended with the sam

symptoms; namely, pain.

The influence of domestication has been

perceived by those who are in the habit of

raising cattle, horses, sheep, c. and we are

assured by them, that many lose their lives

from the difficulties attending their labours. I

have myself more than once seen the mare

and cow suffer extreme agony in bringingforth their young; but it must be admitted,

that this does not occur so frequently as toenable us to establish any proportion between

their pain and difficulty, and that of the hu-

man female; nor would it be of any use, were

it in our power; all that is contended for, is,

that those animals, which man has familiariz-

ed by his care, and made subservient to his

purposes, have suffered, if not in equal degree

with himself, yet sufficiently to justify the po-

sition-that they, in consequence of the habits

imposed upon them, have been rendered les

62

healthy, and occasionally subject to difficultyand pain from parturition.

What the ultimate effect of this familiariza-tion (if we may so term it) may be, we can-not pretend to determine: that it will be moreextensive than it is at present, is renderedmore than probable, from what we have al-ready witnessed.

It is said their uteri alone, are capable ofexpelling their contents without pain, andwithout any assistance from the abdominal

muscles; this may be true; as we are told byVan Sweiten* on the authority of Hemster-huys, "that the womb of a pregnant bitch,"the abdomen being open, by its own efforts

only, forced out the fotus; the diaphragm" and muscles of the abdomen remaining"quiet and yielding no assistance." But canwe determine there was no pain attending the

Comment. vol. xiv. p. 49.

68

efforts of the uterus in this cruel experiment,

since it was placed in a new situation? If painattended, it will not be insisted on, as neces-sary to the delivery, but rather be consideredas the consequence of the increased action theuterus was obliged to exert, to relieve itselfof its load; for although the uterus, unaidedby the auxiliary powers, may be capable ofexpelling its contents, yet it must surely beadmitted, it will do it with more facility withthem. The same may be insisted on, with thehuman female, since pain with them is nothingbut the effect of a certain degree, or kind ofcontraction; neither is it the cause of the ter-mination of their labours, but the result ofthat cause--namely, contraction. Should anequal degree of contraction take place with-out pain, as with it, the labour would be ter-minated with as much speed and certainty.But can this happen with the human female?Certainly it can, and does every day.

The human uterus is as capable of expel-

1ng its contents without the aid o the abdo-minal musclesas that of the brute, and alsowithout the interposition of pain. Of theformer ability, many instances are uponre-cord; many women labouring under ascitehave been delivered; here the auxiliary pow.

rm could give no assistance: children hvalso been delivered after visible life had cea-ed in the mothei by the aid of the uterusalone; here no assistance could be derivedfrom the abdominal muscles. And of womenbeing delivered without pain, it would be idleto cite them, as they must occur i everyman's practice.

Pain then, must be regarded as disease, since

it~ cannot be proved necessary ; this diseasehas its origin in the changes produced by civii-ation and refinement In What do these

changes consist? This we do not pretend toanswer. W might say it is ina peculiar yen-sibility or irritability of the system in general,or in the uterus in particular. But would this

65

explain it? Would not this only be substituting~ie inexplicable phenomenon to account foriinother? We only know with certainty that

these different states exist, but why, or howinduced, it is impossible to say.

We know also, anlmay advance it withoutfear of contradiction, that the female systemduring pregnancy ard labour, is much dispos-ed to that state termed inflammatory; andthat slight causes will produce fever, or localinflammation.* This is acknowledged by all}writers on the sulbject, and has led Dr. Rushto consider pregnancy and parturition, as dis-eases.

That they ought to be considered as pro-ductive of disease, in but too many instancesis certain ; for there are but few cases, in which

*Few facts are better established, than that the blooddrawn from a pregnant woman almost always exhibits the"buffy coat"-with many of the older writers this circum-stance was almost conclusive.

66

we are not obliged to mitigate the violence,or shorten the duration of the symptoms they

produce.

The disturbances which sometimes arise

from pregnancy demand the peculiar care of

the physician in very many instances, that thepatient may not succumb. I have not unfre-

quently seen vomiting carried to great excess;

and it was in one case seriously deliberatedwhether the membranes should not be rupturedto calm the system, when abortion took place

spontaneously during the night and the patientwas rescued from impending death. Besides

the indomitable vomiting just spoken of, there

is a fever which seems peculiar to pregnancy.I never yet have seen any remedy do any good

in this state of the system. It has been reliev-

ed in several instances by abortion; but I oncesaw it prove fatal. Here also it was thoughtjustifiable to produce premature delivery, butthe plan was not adopted; and that parturitionis firequently followed by severe disease iswithin the observation of every practitioner.

67

It is not within our present view to speak

of pregnancy as a cause of disease ;* we shall

therefore confine ourselves to labour and its

consequences.

To relieve pain, has engaged the attention

of physicians from the earliest ages; and their

endeavours have been rewarded with more

success in every other instance in which it oc-

curs than that which attends parturition. This

has arisen, perhaps, from less attention being

paid to it, than to the other states of the sys-

tem in which pain exists, from an idea of its

being inevitable, rather than from the impos-

sibility or difficulty of subduing or alleviating it.

"In sorrow shalt thou bring forth children,"

was the curse inflicted on our first parents for

their disobedience; and from hence it was in-

* We would wish merely to be understood here, that preg-nancy and parturition have their peculiarities; and that theymodify disease to no inconsiderable extent, and also inducea greater liability to it.

68

ferred, that pain was not only unavoidable, butnecessary; I have endeavoured elsewhere* toshow the falsity of this concltsion; we shalltherefore not dwell upon it here, but proceedto show, that the condition of women in thisparticular can be much ameliorated.

The cause of pain and difficulty, for themost part, depends upon a certain conditionof the soft parts that are subservient to labour;we shall therefore consider this subject underthe following heads.

First, where rigidity of the mouth of theuterus depends on the circular fibres maintain-ing their contraction for too long a time, butwhere no inflammation attends.

Secondly, where the rigidity is attended4ith inflammation.

SMedical Museum, Vol. I. No. 111. p. 170.

69

Thirdly, where the rigidity arises fromprevious local injury; either from mechanicalviolence, or from inflammation and its con-sequences.

Fourthly, relative rigidity, or where it pro-ceeds firom disproportionate powers, betweenthe longitudinal and circular fibres.

Fifthly, tonic rigidity, or where the circularfibres, remote from the mouth, embrace thebody of the child too powerfully.

Rigidity of the first kind.

This particular state of the mouth of theuterus, may be divided into three varieties;first, where the subject is very young; second-ly, where the subject has passed the five andtwentieth year, and in labour with her firstchild; and thirdly, where the uterus has beenprematurely thrown into action.

70

Var. t, or where the subject is very young.

In this case, where the subject is very young,and has arrived at the full period of gestation,we very frequently find the soft parts con-

cerned, to yield with great reluctance, andthe labour become extremely tedious and pain-ful. This unwillingness to yield, may arisefrom the uterus not having acquired its com-plete development before impregnation hadtaken place, though sufficiently for the pur-

poses of gestation.* If this be admitted, and

of which we believe there can be no doubt,we shall very readily comprehend why its sub-

* We do not imagine here any imperfection in the uterus;but merely that its development is not final, though suffi-ciently complete as not to defeat the object of sexual inter-course; for we can readily conceive that a female shall be-come impregnated after the first menstrual secretion, yetthat at this period the uterus had not received its ultimatedevelopment; for impregnation depends more upon the per-fection of the ovaria than upon the uterus; and we believethat the woman never menstruates until these bodies aresufficiently perfected for all the purposes for which they weredesigned, as in our opinion it is entirely through their instru-mentality that this evacuation has an existence.

7i

sequent actions should be performed with less

order, or more reluctance, than if it had re-ceived its ultimate finish. It is a fact well

known, that the uterus is one of the last or-gans of the body which is perfected; and nodoubt, connected with this perfection, is that

of the vagina and perineum. If then, impreg-

nation should take place before this period,

the actions of these parts will be less perfect-

ly performed--as the actions of parts, mustdepend upon the condition of the parts them-

selves; consequently, an uterus, Sc. so situated,

cannot act with such order and effect, as when

parts are completely formed, and whose actionsof course are properly established, or can beproperly established, when necessary to be

called forth: hence, in very young girls or wo-

men, we frequently find the labour very tedi-ous. The mouth of the uterus yields unwilling-

ly; the contractions of the fundus and bodyare performed in a desultory manner; the

perinaeum dilates reluctantly, and is in great

danger of laceration; the head or presenting

part will often remain stationary at the inferiorstrait, for hours, owing to the unwillingness ofthe soft parts to give way; so that for the mostpart they are stretched from the mechanicalpressure of the child; the hemorrhoidal veinsbecome much distended; the rectum is moreor less protruded, and inflammation of consi-derable violence supervenes through the wholetrack ofthe vagina, which sometimes terminatesin suppuration or gangrene.

The circular fibres of the mouth of the ute-rus very obstinately maintain their contractionfor a long time, either from their not havingreceived their due organization, and thereforenot acting exactly as intended by nature; orfi'om the longitudinal not having, from somecause or other, acquired their designedstrength, the circular will have a relative increase of it. A great deal of time is thereforeemployed, and much pain endured, before themouth of the uterus will open; and even whenit does, it seems more like being mechanically,than naturally opened. See cases i. ii. iii.

78

Var. 2,* or where the subject is not veryyoung.

The same general phenomena take place

in this variety, as in the first. This kind in

general however is rather more obstinate;the parts, from not having been employedearly according to the design of nature, seemto forget a part of their duty. This kindalso

is more disposed to take on an inflammatoryaction. Much may be done for this varietyproper regimen, +c. 1 few weeks before labour is expected4 See cases iv. v. vi. vii. viii.1x, x,xi.

Var. .3, or where the action of the Uterus s

prematurely excited.

Whatever is capable of exciting the con

*lhere the subject is also supposed to have completed thetero of gestation.

t When consulted by females of this class, somec timebefore the period ot' gestation is comipleted, u niforznly have

K'

74

tractions of the uterus, can produce this va-riety; it may happen at any period of gesta-tion; but it is designed only to speak of it, asit takes place at the latter period of gestation.This may occur in any subject, and in anypregnancy, as the uterus is always liable tobe thrown into action.

It would be useful could we always withcertainty distinguish this variety from the twojust mentioned; as at its commencement itwould require very different treatment. Thisis not always very easy, more especially wherethere is a complete obliteration of the neckof the uterus. We can, however, for the mostpart, do it by the following marks.

First, when the uterus is prematurely ex-cited to action, we can sometimes, (as at the

found that much benefit was derived from their pursuing anantiphlogistic diet, keeping their bowels freely opened, andoccasionally losing blood. I am persuaded, from many casesI have had of this kind, that this plan ha, saved them muchpain.

75

eighth month) feel a portion of the os tinca~e

-Secondly, when we examine the mouth of

the uterus, we find it rigid, both in the ab-

sence and in the presence of pain :-Thirdly,when we pass a finger through the mouth of

the uterus and touch the membranes, we do

not find them so tense, as when the uterus is

naturally disposed for labour:-Fourthly, the

pains are more irregular in their accessions,

and continuance; sometimes quickly following

each other, then more slowly; now long and

severe, then short'and trifling:---Fifthly, there

is no secretion of mucus, nor disposition in

the perimeum to relax :-Sixthly, there is no

immediate subsiding of the abdominal tumour.

When the uterus is thus thrown into action,

if not quickly prevented, it will continue to

contract until labour, strictly so called, takes

place. When this happens, it scarcely ever

fails being tedious and painful. It behoves us,

therefore, to distinguish this state from the

other, that we may, if possible, prevent the

labour coming on. See cases xi. xiii.

76

Rigidity attended with Inflammation andFever.

The cases of difficult labour, attended with

inflammation and fever, occur more frequent-

ly than without them. The three varieties justspoken of, are all liable to these additional

symptoms.

First, from local irritation, either of the

presenting part acting mechanically on the

mouth of the uterus, more especially after the

evacuation of the waters; or from the officious

and ill-judged interference of the accoucheur

or midwife, attempting by force to open it.

Secondly, from improper diet or drink.

When inflammation comes on, the woman

becomes extremely restless, and does not en-

joy that calm which is common at the cessa-

tion of pain; the vagina becomes hot and dry;

the mouth of the uterus thickens and becomes

77

more unyielding; the secretion of mucus, if ithad taken place, ceases; the pulse becomesquick, frequent and hard; the respiration hur-ried; the head much pained; the face flushed;great thirst; the skin hot and dry, or profuselysweating. See cases vii. viii. i. x. xi. xii. xiii.xiv. xv.

Rigidity from local Injuries.

The parts concerned in labour are fre-quently made to suffer by injudicious treat-ment or negligence, a degree of inflammation,that very much deranges their natural struc-ture. Should this inflammation terminate byresolution, it does not do it so completely,as not to leave a thickening of the parts,from which they sometimes never recover;this thickening, which is owing to an un-absorbed quantity of coagulating lymph, of-fers very considerable dificulties to the di-latation of the parts; they cannot assumetheir healthy or natural action while this is

78

present. At other times, when inflammationhas been considerable, an injury may be doneto the neck of the uterus, tc. by the effusionof coagulating lymph, (agglutinating theirfibres as it were) that they cannot ever aftertake on the healthy relaxation; and of coursewill yield with difficulty to the propellingpowers of the fundus and body of the uterus.

When inflammation has been more violentor unsuccessfully treated, it may terminate insuppuration or gangrene. In consequence ofthese unfortunate terminations of inflamma-tion, the parts, if the patient survive, heal upso unfortunately, as to leave large cicatricesin the mouth of the uterus, vagina and os ex-ternum, which will offer immense difficulty tolabour.

These parts are also subject to laceration,more especially the vagina and perimeum.When these wounds heal they present veryfirm cicatrices through the whole extent of

79

the injury. These scars are sometimes sofirm, and so unfortunately situated for labour,that they completely resist for a very longtime, every effort of the uterus to expel itscontents. See cases xvii. xviii. xix. xx.

Relative Rigidity.

The longitudinal fibres of the uterus may berendered so inactive, that they cannot contractwith sufficient force to overcome the resist-ance of the circular. This may happen fiom avariety of causes, but we shall only noticeone, namely, a kind of apoplexy of the ute-rus. This case is known, by labour havingcome on kindly at first, and gradually dimin-ishing in force; by the mouth of the uterushaving a disposition to dilate; by its thicken-ing; by the presenting part not protrudingduring pain; by the pain extending itself allover the abdomen; by the woman's complain-ing of a sense of suffocation; by a hard and

80

full, or depressed or labouring pulse; by the

irregularity of the pains both in force and fre-

quency. The mouth of the uterus in these

cases cannot open, although disposed agree-

ably to the order of nature, as the fibres desti-

ned to keep it shut are relatively stronger

than those intended to open it.

The contractions therefore of the longitu-

dinal fibres, are feeble and transitory; the

mouth of the uterus does not dilate, though

not positively rigid; the abdominal tumour

does not continue to subside; there is a secre-

tion of mucus, and a disposition in the exter-

nal parts to dilate, which perhaps pretty

clearly points out the favourable situation of

the mouth of the uterus; but it cannot dilate

until the longitudinal fibres have shaken off

their torpor; or in other words, until the

cause of this torpor is removed; they then

resume their healthy contraction, and the la-

bour is for the most part quickly terminated.

See cases xxi. xxii.

81

Tonic Rigidity.

This only occurs where the waters havebeen drained off a long time, and the wholeof the internal surface of the uterus is closely

applied to the body of the child. Such is thenature of the circular fibres, that they alwayscontract in such a manner as to come in con-tact with the substance present in the uterus;they do not however do this suddenly; it re-quires some time; and in proportion to that

time, other things being equal, will be theintimacy of this contact. While the child isstill in the uterus, it must necessarily presentto it some inequalities; but such is the ar-

rangement of nature in general to guardagainst this disposition of the uterus, that the

body of the child is so placed as to offer as

few as possible. But the care of nature in thisparticular must be often thwarted, by acci-dents of various kinds, which are capable ofretarding the labour; for instance, suppose

TA

$2

the mouth of the uterus well opened, the wa-

ters discharged, the head of the child some-

what advanced, when something may happen,

no matter what, that will delay the delivery

of the head, or obstruct its progress; what

will b the consequence? the uterus will ap.

ply itself to the body of the child, and be dis-

posed to do it at all possible points; the head

being in the pelvis, the neck of the child is

more or less extended, and will offer a much

smaller volume to the parts of the uterus near

it than the rest of the body; the circular fibres

will go on contracting at this part until they

embrace the neck; this will divide the uterus

into two chambers as it were, and in conse-

quence thereof the labour will be delayed,

and turning rendered impracticable; hence

the difficulty of this operation after the wa-

ters have been long evacuated. This peculiar

contraction has been mentioned by authors,

but none, as far as I know, have ever offered

a remedy for it.*

SSee Baudeloque, Smellie, &c.

88

This case occurs sufficiently frequent tomake it an object of particular attention; asmany infants, I fear, have been sacrificed tothe crochet, from this cause intercepting de-livery. See case xxiii.

Having spoken as concisely as the natureof the subject would admit, of the variouscauses of rigidity, we shall now proceed tosay a few words on the principal remedieswhich have been employed with a view to

relieve it: they are opium, the warm bathand blood-letting.

Opium.

This has been, and still continues to be, thefavorite remedy with most accoucheurs, for therigidity of the os uteri; but we conceive, no-thing but theory has ever given it employment;it was supposed, that when the mouth of theuterus did not open kindly, it was affected

84

with spasm, and on this principle was opium

exhibited; but as far as my experience goes,never with advantage. I have repeatedly tried

it myself, and have often seen it employed byothers, but without in a single instance, pro-

ducing the effect for which it was prescribed;

sometimes it evidently did harm.

It must be remembered we are speaking of

it, as given for the express purpose of dilatingthe os uteri, or disposing it to dilate. It.hasundoubtedly been used with advantage, inthose cases where it was conceived the uteruswas prematurely excited to action-it has

suspended the contractions for the proper

time, and when they were renewed, the uterus

was healthily disposed, and the labour soon

finished; but here it was given, not to dilate

the mouth of the uterus, but to suspend the

contractions of the longitudinal fibres. This

medicine cannot, we conceive, ever be recom-

mended with any chance of success, where the

object is directly to make pains more efficient,

85

by taking off the resistance of the mouth of

the uterus.

Nor can this drug be considered as an in-

nocent one; that is, if it does no good it will

do no harm; on the contrary, we believe it to

be extremely mischievous ;* in many cases

converting the rigidity without inflammation

or fever, into those with them; this I have

more than once seen, and but too frequently

had reason to regret.

Warm Bath.

I shall beg leave to transcribe the observa-

tions I have before made on this remedy, from

2d vol. No. II. of the Medical Repository of

*I have in a number of instances seen opium exhibitedwith a view to mitigate the severity of pain, where the labouradvanced slowly, and have never failed to observe that theforce of contraction was diminished at the time it was re-qured to be the strongest.

86

New.York. It was written in consequene of

a request of one of the editors of that work-

Dr. E. H. Smith.

SThe warm bath is by no means a ne

remedy in that species of labour*, in which I

have thought blood-letting of so much conse-

quence. Few writers on the subject of mid.

wifery have failed mentioning it, among other

means to overcome the rigidity of the soft

parts in laborious labours, that do not depend

on a mal-conformation of the pelvis. The

French accoucheurs more particularly make

frequent mention of it; yet none of them, that

I am acquainted with, have laid any particular

stress upon its virtues in these cases, or place

any great dependence on its effects. It has been

rather recommended as a probable, than as a

certain remedy, and stands upon much the

same footing as opium-sometimes perhaps,

succeeding, but much more frequently failing;

* See Med. Rep. vol. .

87

with me it has ever been of little or no con-

sequence; nor can I obtain a more favourable

character of it from the friends I have con-

sulted.

"The result then, of my experience, enqui-

ries, and observations, may be reduced to

three heads:

First, It being almost always inconvenient:

Secondly, It being sometimes ineligible;and

Thirdly, it being always limited and uncer-

tain in its effects.

"The very great difficulty that attends thewarm bath, makes a very strong objection toits use; or, in other words, renders it almostimpossible to be employed, as very few people

are in possession of a suitable apparatus. Itmight, however, on extraordinary occasions be

procured with some difficulty; but much timewould be lost, particularly in the country, where

this kind of labour is by far the most frequent.The lancet we may always have at hand."

88

" It is sometimes ineligible; occasioning isome instances, very profuse and alarming

haemorrhages. A fatal instance of this kind

happened not long since, in the practice of a

physician in the neighbourhood where I for-

merly lived. It was universally attributed to

the warm bath; and the Doctor himself, in a con-

versation with me, inclined to the same belief;

at the same time assuring me he derived no

advantage whatever from it, as the parts were

no more disposed to yield than before; and

the woman eventually suffered a lacerated

perineum. The warm bath in this instance

evidently did mischief, by preventing the tonic

contraction of the uterus from taking place,

whereby the vessels were not contracted upon,

and a fatal hiemorrhagy ensued. This is not

the only instance in which it has done harm

in this way. A Dr. Tom, who had an extensive

practice in this line, and who was in the habit

of employing the warm bath in these cases,

informed me, he never failed producing a

more than ordinary flow of blood from the

uterus; and in some instances to an alarming

89

degree. He urged however, in defence of its

that he knew of nothing better-Opium had al.ways failed with him--and that he considered

the warm bath as a dernier resource, adding,

he sometimes thought it had done good. Be-

sides, cases occur where we could not leave

our patients sufficiently long to derive any ad-

vantage from the bath, were any to be expec-

ted, without running a risk of the most dread-

ful consequences ensuing: for instance, the

case I sent you some time since.* In this case

it would have been impossible for me to have

left my patient a minute for her to have been

placed in the bath, as it needed not only all

my care, but likewise great exertion, to prevent

the head of the child escaping through the

anus, 4c. Again, the inconvenience, nay, the

almost impossibility of rendering the woman

proper assistance when in the bath, will readi-

ly occur, and will be an additional objection to

its use. But above all, the extreme indelicacy

SSee Med. Rep. vol. II. p. 24, or case xvii. of this Essay.M

90

that must appear when employed in that situa-

tion, were it practicable, would be sufficient to

render it the dread of the woman, and the

aversion of the modest practitioner."

" With me, and my friends, it has always

been limited and uncertain in its effects; so

much so, (as I have already observed) as to

be of little or no consequence, its influence

having never extended beyond partially relax-

ing the more external parts, and even this

continuing but a short time after the bath has

been desisted from. I have never known it to

have the least effect on the neck or mouth of

the uterus; nor can I find it has ever done so,

unequivocally, in any instance, as far as my

inquiries have extended. It frequently pro-

duces no effect whatever, not even on the ex-

ternal parts. And should it even relax these,

no great advantage would be derived as long

as the mouth of the uterus continued rigid;

and I cannot find it has ever had this effec.

The yielding of the neck of the womb ap-

91

pears very often to be a distinct process, from

the relaxation of the other soft parts; at least

they do not always keep pace with each

other; having frequently seen the uterus well

dilated, with a very rigid os externum, and

vice vers; the one attended with an increas-

ed secretion and discharge of glary mucus;

whereas the other is not accompanied with

these marks. The vagina and external parts

sometimes, after having been well relaxed,

become again rigid and unyielding; but the

uterus, after having been once well dilated,

never (as far as my observations extend)

closes, and makes resistance, until after the

expulsion of the child; so that it appears that

all these parts are not influenced at all times,

by the same laws or causes.

"It may at first sight perhaps appear a pa-

radox, that in some cases I should fear the

warm bath producing a too great discharge of

blood from the uterus, and directly after as-

sert, that in no one instance could I 1find it

92

had any effect on the os uteri. But I do notperceive any contradiction here, as every body

must admit, that the development of the neck

of the womb, or its perfect expansion, must be

a very different process from its tonic contrac-

tion. In the one instance, a peculiar arrangement

of the fibres which constitute the neck or mouth

takes place, so as to allow of the passage of

the child, Vc.; whereas, in the other instance,the power which reduces the uterus to its ori-ginal size after the expulsion of its contents,

and by which a too great discharge of blood

is prevented, is diminished,-hence hemor.rhagy. And we may safely, I think, in someinstances conclude, that the warm bath, al.though it does not produce relaxation, may

yet prevent contraction.

"Besides what I have urged above, I mustnot omit telling you I have experienced, inthe most convincing manner, the superiorefficacy of blood-letting, to the warm bath. Acase occurred that put the two remedies, I

98

think, to a very fair trial. A woma beena long time in labour, and from therigidityof the parts concerned, the midwife, enter-taining no hope of a speedy delivery, thoughtproper to send for a physician. He orderedthe warm bath, and thirty-five drops of lauda-num; these not succeeding as he expected,the woman was again ordered the bath andthe anodyne. Several hours were spent in thisway; the woman every hour or two was pla-ced in the bath, and took fresh quantities oflaudanum; but all without benefit. I was nowcalled in. It was agreed that the woman shouldbe very fully bled; this was done. When uponthe loss of about thirty ounces of blood, shegrew very sick and faint; her friends becameuneasy, and would not allow the bleeding tobe carried to complete fainting. I was obligedto tie up the arm and rest satisfied with whatwas already drawn; this fortunately provedsufficient; for the parts began immediately torelax, and in about three quarters of an hour,she was made the happy mother of a livingchild."

94

I shall only add, that subsequent experiencehas more fully confirmed me in the opinionthat the warm bath by no means offers a sub-

stitute for blood-letting.

Blood-Letting.

This remedy is by no means a new one in

labour; but employed for the express purposeof diminishing pain, and subduing the variousspecies of rigidity just spoken of, and carriedto an extent that will insure these objects,that is, diminishing pain; disposing the osuteri to dilate, the external parts to unfold,

and cicatrices to yield; originated, as far as Iam acquainted, with myself. This remedy wassuggested to me by accident, but has eversince been employed from reason and expe-rience.

In the summer of 1789, I settled at Abing-ton, and was quickly introduced to a large

95

share of obstetrical practice; in September of

of that year my attendance was bespoke for

Mrs. H. W---, whom I was informed had

suffered every thing but death from her la-

bours ; the crotchet had several times been em-

ployed to effect the delivery of her children.

She looked forward with great solicitude and

apprehension, and indeed almost considering

herself a certain victim to the approaching la-

bour. 1 had also very great fears for my patient,

as I was young, and had not had much expe-

rience; these forebodings were presently very

much augmented, by my being called to her

under a severe hiemorrhagy from her lungs,

which quickly reduced her to a state of extreme

debility. Before she recovered from this state

of weakness she was taken suddenly in labour,

which increased my apprehensions almost to

despair, lest she should die under my hands.

As I approached the house, I was met by seve-

ral of her friends, who with great earnestness

begged me for God's sake to make all possible

haste; I proceeded immediately to her bed side,

96

and in about fifteen minutes delivered her ofa fine healthy child; no accident supervened;she had a much better getting up than couldpossibly have been expected, from the extremestate of weakness she was in, when surprisedby labour.

As this was so very different from all herformer labours; as it was easy, rapid, andsafe; and more especially when a result sovery different had been expected, I could not

help being very powerfully struck with thecircumstances. I had to reason very little onthe subject, for it immediately occurred, it

could be from no other cause than relaxation,

produced by the excessive and alarming he-morrhagy. I quickly resolved to take advan-.tage of this kind hint, by endeavouring toimitate this good example. I had not to wait

long before I had an opportunity of putting

my new plan in practice; a Mrs. M. M- ,who had suffered in almost an equal degree

with Mrs. W-, in her labours, was under

97

the care of a midwife; she had been in labourten hours; I found her with considerable fe-ver; a hot and dry vagina, and rigid os uteri;pains frequent and severe, but without muchbearing down, as it is termed. I immediately

bled her pretty freely; but this had not theeffect, of either relieving her fever, or givingdisposition to the mouth of the uterus to relax.At the expiration of half an hour, I again bled

her to a considerable extent; that is, until shebecame very sick and weak; upon examina-tion I found the mouth of the uterus suff-

ciently opened; the vagina moist; and theexternal parts completely disposed to yield;the pain from the contraction of the uterus

considerably diminished; and the labour was

shortly terminated. This case I considered ofimmense consequence, as it appeared to put

me in possession of a certain remedy for thiskind of labour.

It would be unnecessary to relate all theeases in which I advantageously employed

N

98

this, I had almost said divine remedy; many

of the women of Abington speak of it in rap-

turous effusions of gratitude. In December,

1793, I again returned to this city, where I

have continued with all my former success,

to employ this remedy, even in. cases where

reason could scarcely bid us hope for it.

We can, with a confidence that should only

be produced by experience, recommend this

operation, not only as a safe, but a certain re-

medy, for all the objects we have just con-

templated; and we feel the more security in

doing this, since it met the approbation of the

late venerable and experienced professor of

anatomy and midwifery, Dr. Shippen; who

declared with a candour which did him ho-

nour, he could have spared much pain and

misery to many of his patients, had he used

the lancet more freely in tedious and painful

cases from rigidity.

We shall now proceed to relate a few cases.

99

selected from many, which will illustrate the

practice, in the various kinds of rigidity we

have spoken of.

VA R. 1. CASE I.

Miss V- , aged fourteen years and six

months, was taken in labour January 14th,1790. She had been in labour thirty-six hours

before I saw her; that is, she complained of

pains for that period, though they were not

very severe; about twelve hours before I vi-

sited her, the waters were discharged; the

mouth of the uterus very little opened, and

the external parts not favourably disposed;

the pains were now very severe, and the head

was pressed pretty far into the pelvis; she

was extremely costive, and had passed no

water for many hours; an injection was or-

dered, which operated freely; the catheter

was obliged to be introduced, and nearly a

quart of water was drawn off; she was much

relieved by these discharges; an hour was

given in hopes a favourable change might

t0oo

take place in her labour; there was no heat

of any consequence in the vagina; she had

been very rarely touched; she had frequently,

by the midwife's advice, been placed over

warm water, and fumigated with burning

onion-shells, (a favourite remedy with the old

women of the country) but all to no purpose;I bled her fifteen ounces; this produced some

little change on the mouth of the uterus, but

not sufficient to allow the head to escape,

more especially as the mouth contracted and

stiffened with each pain; in an hour she was

bled as much more; this produced sickness

at stomach, which was my signal for stop-

ping; upon the next examination the parts

were found sufficiently dilated; there was a

short suspension of the pains, but they soon

returned, and were found of competent force,

though much more tolerable; the labour soon

terminated.

CASE II.1790, June toth. Mrs. S. F. aged fifteen

dears and a few months, had been in la-

101

bour ten hours, when I was called; the head

had nearly escaped from the uterus, and

was applied very forcibly against the peri-

nteum; the os externum small and rigid; the

head, as I was informed, was thus situated

more than three hours, without the least ob-

servable alteration; the midwife very judi-

ciously made a firm pressure against the ex-ternal parts. She was bled very liberally; the

parts almost immediately yielded, and the

head passed without difficulty or laceration.

This labour, without doubt, was rendered safe

and mild by the bleeding, as I am persuaded

that it would have been protracted much lon-

ger, besides the risk of laceration.

CASE III.

1792, June ti th. Mrs. F-, aged seven.

teen, very small of her age, never menstruat-

ed until after marriage; was taken in labour

with her first child; pain came on verygra-

dually for the first few hours, then augmented

very considerably for some time, and then

102

subsided almost altogether; this flagging of

the pains was considered as a proof of weak-

ness, and to obviate it, stimulating drinks

were liberally given; pepper, thyme, ginger

and onion-tea, had each their trial, without

advancing the labour. Her friends became

alarmed, and I was sent for; I found her with

much fever, severe pains, profuse sweats, hot

vagina, swelled labia, and rigid os tine. I

proposed to bleed her, but this she would not

permit; she was placed in the warm bath by

way of substitute; mild drinks were given, and

her bowels were opened by injection. Warm

water was frequently thrown up the vagina,

but without any observable effect; I again

proposed the bleeding, but it was again re-

jected. As I had observed that bleeding had

done good almost in the proportion to the

sickness it excited, I thought of giving emetic

tartar in small doses until nausea was produc-

ed; I soon brought the stomach to this state,which was kept up with considerable severity

bfor two hours, but without any good effect. I

108

now urged the bleeding as the only chance of

benefiting her; to this at length she reluc-

tantly submitted; she was bled twice in an

hour, the last of which was copious, and had

the long looked-for effect; the uterus dilated

almost instantly after the bleeding, and the

external parts yielded without any difficulty:

the child was delivered in half an hour.

VAn. 2. CASE IV.

1790, August 80th. M. M. in labour with

her third child; she had suffered very severe

pains for thirty-six hours; the waters had been

evacuated twelve hours; the vagina hot, and

dry; the external parts much swoin; the

mouth of the uterus thick, firm, and but little

dilated; much fever; bounding pulse; severe

head-ache; great thirst; much anxiety and

restlessness; I bled about fifteen ounces, but.

with no evident advantage; at the end of an

hour she was bled twenty ounces more; this

seemed to affect her considerably; but its use

was but transient; she was presently bled

104

twenty ounces more; she became extremely

sick; the parts quickly dilated, and she was

delivered in half an hour more.

CASE V.

1799, February Ist. Mrs. M. A-, aged

twenty, with her first child; the first part of

her labour was quickly performed; that is, the

mouth of the uterus opened easily, but the

perimeum offered immense resistance-it was

very thick and dense, and as soon as the pain

ceased, the head of the child would recede

very considerably: several hours were spent

in the expectation that this part would yield;

my patient became very uneasy, and I pro-

posed bleeding-she consented most willing-

ly; I was obliged to send for a bleeder for

her, as I could not be spared from the peri-

nmeumni, lest when pressure was removed, it

would suffer laceration. After about twenty

ounces had flowed, I found an evident change

in the parts, and before ten more were drawn,

the child was delivered.

105

CASE VI.

1798, February 17th. Mrs. S. C. aged forty,

with her first child; she had been long in la-bour before I saw her, and suffered much

pain; she had pains in very quick succession;

the waters were still undischarged; the uterus

opened to about the size of a quarter of a dol-

lar, its edges very firm; no disposition in the

external parts to relax. She was bled very

largely, (forty ounces), and was delivered in

half an hour.

CASE VII.

1796, June 18th. I. 8-, aged thirty-two,

with her first child. She had been fourteen

hours in labour; the head was low in the pel-

vis, and escaped from the mouth of the ute-

rus; it pressed violently against the perinmeum,

which showed no signs of quickly yielding.

She was bled, standing on her feet, twenty

ounces; she became very sick; the parts yield-

ed soon, and the head passed with a few

pains.O

CASE VIII.1799, May 18th. Mrs. T. aged forty-one,

with her first child. She had suffered 'pain fortwo days and two nights without any apparentadvancement of the labour. I was sent for,and from the little appearance of relaxation,and the desultory returns of her pains, I ra-ther thought it would go off for a few days.With a view to prepare her for the exhibitionof an anodyne, I bled about sixteen ounces,and she fainted; there was a suspension ofpain for an hour or a little more; at the endof this time they returned in quick and regu-lar succession, but with considerable abate-mnent of severity. She was delivered in lessthan another hour.

Many more cases similar to the above,might be given, but we deem these every waysufficient for the purpose for which they areintended,

107

CASE IX.

1791, January 5th. Mrs. A. H. C. in labour

with her second child. She had suffered many

hours, without evident advantage; she had

great thirst, fever, and anxiety; she had slept

none from the time she had been taken; skin

parched; the vagina hot; the mouth of the

uterus nearly closed; no secretion of mucus.

She was bled to sickness; this was produced

by a very few ounces, as she was much alarm-

ed at it-no change was produced; she was

again bled in an hour, with some advantage;

that is, there was less fever, pains not so se-

vere, the parts less hot; but the uterus remain-

ed in statu quo; she was again bled in ano-ther hpur, with the happiest effect. The child

was soon delivered, and the mother had a

rapid convalescence.

CASE X.

1797, July tioth. Mrs. Le B-.-.--, in labour

with her third child; the arm presented and

108

had been down twelve hours; much fever,dry skin, great restlessness and anxiety, facemuch flushed; pains not frequent, but verysevere; the vagina hot and dry, for she hadbeen much handled; the child's arm very

much swelled, and the mouth of the uteruswas contracted closely round it, and was veryrigid; there was no possibility of turning,under these circumstances. She was bled up-wards of eighty ounces in five bleedings, in asmany hours; the last bleeding produced faint-

ing; the mouth of the uterus relaxed, and thechild was turned without difficulty. This ladyfeels her after pains in her right knee; thishas obtained with all her children-they areas regular as when felt in the region of theuterus.

CASE Xl.18o2, January 29th. Ph be Hall, a black

woman, in labour with her seventh child: armpresented and had been down several hours;the arm considerably swelled, as the midwifehad exerted much force on it; the mouth of

109

the uterus contracted closely on it; I got Mr.

Carter, now Dr. Carter, to introduce his hand

into the vagina and place a finger in the

mouth of the uterus; he did this with some

difficulty, as the uterus was very rigidly clos-ed on the arm. I tied up her arm and let her

bleed until he should tell me the mouth of

the uterus was sufficiently dilated; when I had

drawn from forty to fifty ounces she became

sick and faint; at this instant Mr. Carter cried

out with rapture, the uterus was sufficiently

opened--upon examination this was found to

be the case; the turning and delivery was soon

accomplished.

It must be observed, that labours attendedwith fever, have always been found to require

considerably more bleeding than where none

attends; and it has also been found best in

these cases, to draw blood at two or three

times, letting the last be carried either tofainting or sickness.

40

VAR. 3. CASE XII.

1790, January 29th. Mrs. M. L with

her first child, aged twenty; after having

stood all day at the ironing table, was seized

with pretty regular pains. There was no sub-

siding of the abdominal tumour; no secretion

of mucus; the os tingce was not entirely ef'a-

ced. There was very little tension of the mem.

branes during a pain; from these circum-

stances I was disposed to believe the uterus

had been prematurely excited" into action;

she was ordered to lose twelve ounces of

blood, to keep quiet, and receive an enema

of a gill of water and a tea-spoonful of lauda-

num-pain soon subsided, she went a fort-

night longer, and her labour proceeded kind-

ly, and was not of long duration.

CASE XIII.

1790, August t th. Mrs. C- , pregnant

of her third child, aged twenty-eight; after a

severe fright was seized with pains ; as her

111

midwife was engaged at the time she was sentfor with another patient, I was called on;from her not getting her midwife, she becamevery much alarmed, and her pains ceased forsix hours. At the expiration of this time theyreturned; and soon after the midwife arrived;she examined her, and found nothing like la-bour; she therefore gave her a large dose oflaudanum, which not having the desired ef-fect, was repeated, in the course of twohours; her pains became more violent; shehad much fever, and attended with delirium.I was again sent for; upon examining thestate of the uterus, I was pretty certain it hadbeen forced into contractions by the fright inthe first instance; and continued in this situa-tion by the improper conduct of the midwife;but things had now come to that pass, that itwould have been in vain to have attemptedstopping their progress. The mouth of theuterus was thick and hard, and opened toabout \the size of half a dollar. As there wasso much fever, I thought proper to bleed and

I2

purge her; these had a good effect, as h

fever and delirium were diminished, but the

uterus was still finnrm, and not augmented in

size since she was examined before; (six

hours) I again bled her pretty largely, the

delirium went off entirely, the uterus opened,

and she was delivered in less than an hour.

I am disposed to believe this case would

have had a serious termination from the vio.

lence of the symptoms, had she not been bled

very liberally: she lost about fifty ounces at

the two bleedings.

This case also serves as a contrast to the

case preceding; for I have no doubt but what

the bleeding which preceded the anodyne,

enabled the latter to produce its beneficial

effects; and I am also equally certain that had

a bleeding in this latter case been premised,

the patient would have sufifered abundantly

less, and gone some time longer.

I18

CASE XIV"1805, February tath. Mrs. C-.-., with her

first child; she had been forty-eight hourslabour when I was called; the waters had di-charged fourteen hours-hr pains severe butirregulair; the mouth of the uterus opened to

about the size of a quarter of a dollar, but

very rigid; the vagina, 4c. very hot and ten-

der; pulse frequent and hard-she supposed

she had just entered her eighth month, and

was seized with pains in consequence of a

fall; a midwife was sent for, and she 'edea-

voured by stimulating drinks,* frequent and

rude touching, to provoke labour. She was

bled twice in four hours, to the amount of

twenty-two ounces ; received a purgative in-

jection, which operated well, but without pro.ducing any change in the uterus. The head

This patient took, by the directions of her midwife, in thecourse of forty-eigt hours, three pints of wine, one of brand-dy. a large quantity of strong black pepper tea, witha viewto force her labour as it is termed.x

114

presented naturally. Two hours more were

allowed to pass, with a hope of things doing

better-but no alteration being produced, I

made Mr. King (a young gentleman who staid

at my request with the patient) tie up her arm

while standing on her feet, and take blood

until she nearly fainted; she was then laid in

the bed, and after an exemption from pain for

about fifteen minutes, they came on very ra-

pidly; the mouth of the uterus was found

completely dilated, and the child was deliver-

ed in a quarter of an hour more.

CASE XV.

This case was kindly furnished me by Dr.

Shaw, I shall therefore relate it in his own

words.

DEAR SIR,

The following is the statement of Mrs. M.

Q- 's case; I give it you as correctly as

circumstances will admit.

"15

Saturday, 5th October, 1805, this womanwalked from the country to Philadelphia, adistance of twenty-three miles; agreeably toher calculation she was entering her eighthmonth of prognancy. On Friday the t ith,symptoms of labour were felt; that is, she hadpain in her back, side, c. accompanied withalternate flushes and chills; these symptomscontinued until Monday, when she was attack-ed with an hemorrhage from the uterus. Amidwife was sent for, who mistaking hercase, immediately attempted delivery by rup.turing the membranes and discharging thewaters, but finding her efforts ineffectual, afterdoing considerable violence to the vagina andneck of the uterus, by her frequent and offi.cious examinations, left the woman undeliver-ed and without pain. She remained in thissituation until the following Wednesday after-noon, at which time I was called to her;slight pains had returned, and on examinationI found the parts very much swelled, andpainful to the touch-the mouth of the uterus

116

was not dilated more than an inch in diame-

ter. About half past ten o'clock, P. M. her

pains became stronger, but the mouth of the

uterus showed no disposition to dilate-

agreeably to your friendly advice I had her

taken out of bed and placed in an erect posture; a vein was opened in her arm, and bythe time sixteen ounces of blood were drawn

syncope came on, and she was immediately

replaced in bed--after she revived, her pains

increased, but the mouth of the uterus still

remained contracted; at half past twelveo'clock (Thursday morning) about six ounces

more of blood were taken, which also pro-duced fainting; she was now examined, and Ifound the mouth of the uterus dilated to aboutthree inches--after she had recovered so asto take a little wine and water, a few smallpains came on, and at ten o'clock she was

safely delivered.

Yours sincerely,

WILLIAM SHAW.Oct. 22d, 1805.

"?

We might easily increase the number of

cases of this kind, were it necessary; but as

these cases resemble so exactly those alreadyrelated, after the uterus refuses to be tranquillized, that to give more would be mere

repetition. We would, however, suggest two

rules in the management of these labours;

first, always try to quiet the uterus, when we

have reason to believe its action has been prematurely excited, by first bleeding, and thengiving laudanum by injection. Secondly, whenwe find we-cannot suspend pain, to be carefulto abstract all stimuli as much as possible; tohave the bowels well opened; and allow thecircular fibres of the mouth to be a little fa-tigued (which we can determine by theirreadily yielding, when the finger is made tostretch them i7 the absence of pain) beforewe employ a large or a sufficient bleeding toeffect the farther dilatation.

Bleeding alone, sometimes quiets this pre-mature commotion of the uterus, as the fol-lowing case will prove.

lA8

CASE XVI.

1806, January toth. Mrs. C -, aged

4ineteen, and subject of case xiv.; pregnant

of her second child, was attacked with pains,

which she bore all night; in the morning I

was called to her; she seemed to suffer much,

but from examination was certain the pains

were premature; her pulse was full and tense;

she lost twelve ounces of blood, which very

much diminished her pains,' but did not sub-

due them: in the evening, her pulse continu-

ing still active, she lost as much more, and

was very soon entirely relieved. In about a

fortnight after, she was again seized in the

same manner; she was again bled and obtain-

ed ease: at the expiration of another fortnight

she was again attacked; these were the ge-

nuine pains of labour, and she was delivered

in about two hours.

119

Rigidity from local Injury.

Notwithstanding my frequent use of blood-letting in certain cases .of difficult parturition,I was an entire stranger to its effects wherethe parts had suffered considerable derange-merint from inflammation or laceration, as nocase of the kind had ever came under my no-tice until the time I was called to the subjectof case xvii.; and perhaps I might still have

remained ignorant on this head, had not myfriend Dr. Physick proved, how much couldbe done in a forlorn hope, by bleeding ad

deliquium animi. I have no doubt, from for-

mer experience, but I should have employedthis remedy to a very considerable extent inthe cases under consideration, but must con-

fess I think it more than probable I shouldnot have ventured to produce syncope in casesof cicatrized vagina, Vc. as relaxation couldnot be anticipated from any remedy, had notits safety been proved by previous experiment.

420

But I am now so well satisfied of its safety

and its extensive usefulness, that I should

never, in cases judged proper for the trial,

hesitate a moment to enmploy it. I have ear-

nestly inculcated its safety, and I trust have

proved its usefulness. I would remark here

from long experience, that I have never

known it fail in being serviceable, nor ever

saw it in any degree do harm. The following

cases will confirm its power, where had it

failed, no resource would have been left but

in the application of cutting instruments.

There are instances on record, where thisalternative has been employed, where I am

disposed to believe, bleeding ad deliquiumwould have succeeded. Baudelocque, one of

the most scientific and experienced accou-

cheurs of the age, Vol. III. p. 205, par. 1960,

says, "Sometimes the pad which constitutesthe neck of the uterus in the later periods of

pregnancy and in the time of labour, is hard,

scirrhous, incapable of any extension or dila-tation, so as entirely to hinder the exit of the

121

child. After a euenient delay to ascertain

that the efforts of ture cannot overcome

the resistance, and the administration of pro-

per methods to relax it, it must be cut in

several places, as some practitioners have

done. Those incisions are preferable to rents,

which might take place in it, and have never

been attended with the same consequences."

"The orifice of the uterus may be closed,

either completely or incompletely, at the time

of labour. Its perfect closure is always pos-

terior to conception, but an incomplete one

may exist before. In all cases, the orifice must

be restored to its original state, and be open-

ed with a cutting instrument, as soon as the

labour shall be certainly begun."*

I have been most illiberally charged with misquotingBaudelocque, in these passages, by a writer in the Philadel-phia Medical and Physical Journal-I have carefully exam-ined the paragraphs, and find them word for word-I usedHeath's Translation; the original I never saw but for a shorttime, to compare the translation in many parts with it. M

q

122

Would it not be better in such cases alwaysto trr first the effects of blood-etting? And dnot the following ases rant belief itwould succeed?

CASE1~ XVH.In June, 1796, Was called to Mrs. T---,

in labour with her second chid. The follow-ing account I received on my arrival, from thenwife. "She hadbeenilaour sixteenhours; the waters discharged,sx the mouthof the womb but little opened; and whenpain the os xten seemed t close up.Many things had been given her to fore thelabour; but the child was still as high tsever.She had passed no Water for twelve hour, andwas very costive."

I found her very feverish ; complaining of'great heat in her abdomen, and violent pain

iher head. Onexamining per vagiam,I

*See Med. Rtepos. Vol. II. No. 1. p.4 2.

128

found, as the midwife had stated, that the os

tince was but little dilated, its edges very

rigid and hot--as was the whole tract of the

vagina; the rectum much distended by har-

dened fieces, and the bladder considerably by

urine. The head of the child was still above

the brim of the superior strait; but could not

exactly determine its situation with respect to

the pelvis, as the os uteri was not sufficiently

opened for this purpose.

I immediately bled her twelve or fourteen

ounces and ordered an injection, which pro-

cured two stools, and a discharge of urine. I

again examined her, and found the mouth of

the uterus more dilated (it being now opened

to about the size of half a crown) which ena-

bled me to determine the precise situation of

the head. It was a perfectly natural presenta-

tion, and the vertex had now descended lower

into the pelvis. The pains were very power-

ful. The head at length cleared the superior

strait, and the vertex wa about to turn under

124

the arch of the pubes, but completely envelo-

ped by the uterus---during pain the perinue

was much distended; the os externum, instead

of yielding to the impulsive force of the ute-

rus, rather closed, so that two fingers could

not be retained; a seam or cicatrix, from her

having had the perimeum lacerated in her

former labour,* formed a kind of barrier;

and the head, in consequence, was thrown to

the right side of the inferior strait, where the

parts were so extremely stretched, that I fear-

ed each pain would make the head burst

through them, in spite of every exertion tothe contrary.

From the oblique situation of the head with

* The laceration ran from the inferior termination of theleft labium, to about the termination of the sacrum. I judgedof the extent of the injury by the cicatrix, which could beeasily traced to this place. And indeed, conversing with thegentleman who had delivered her, he confirmed my supposi-tion. It was a long while healing; and her health sufferedmuch from the excessive and long continued discharge. Butfrom this she recovered, and when I saw her she appearedin robust health. She was about twenty-two years of age, ofshort stature, and rigid fibre.

125

respect to the vagina, the os externum, insteadof answering to the axis of the inferior strait,mounted directly to the pubes; and conse-quently, the right side of the vagina, peri-naum, and rectum, had to support the majorpart of the force exerted by the uterus and itsauxiliary powers. In order to counteract theirinfluence, I supported the external parts with

my hands, and made, during each pain, a

strong pressure against the head, and direct-

ed the woman to suspend her voluntary

powers as much as possible. Six hours were

spent in this manner, without advantage; the

os uteri still rigid, hot, and but partially dilat-

ed; the os externum still not disposed to yield;

and the cicatrix as firm as ever.

The head, notwithstanding my efforts to

prevent it, advanced; so that the vertex, co-vered by a portion of the uterus, had partly

emerged from under the pubes. At this period

it was extremely difficult to touch the mouth

of the uterus, as it had receded towards the

126

sacrum in proportion as the vertex had de,stended. The soft parts were very hot anddry; I began to be much alarmed for the fateof my patient. What to do I did not wellknow: I was ten miles from the city, and noone near me on whose judgment I could rely.In this dilemma I had nearly resolved on di.viding the parts, thinking this preferable toletting the head force its way through them,which I began to consider inevitable, whenfortunately Dr. Physick's case of luxated hu.merus occurred to me, and determined me totry the effects of bleeding ad deliquium animi.I represented to the friends of my patient,

the danger of her case; the possible result ofthe bleeding; and the inevitable one did it notsucceed. They agreed to the trial. I had herplaced erect, while the midwife strongly sup-ported the perimeum, "c. and opening a veinallowed it to bleed until she fainted.* She wasthen again placed on her side.

SThe quantity drawn was upwards of two quarts.

t21

On examining her now, every thing appeared better; the external parts were perfectlysoft and yielding, and the os uteri pretty fullydilated: but no pains succeeded.Iwaitedthis way half an hour (tepatient connuing very faint) and no pain coming on, and

the parts being now in a proper situation fordelivery, I introduced the forceps, and deli-vered a living, and healthy child. The partsvery readily yielded without laceration: the

womani had a rapid recovery.

CASE XVII*On the 12th of September, 1 798, 1 w re"

quested to visit the wife of Samuel Griffith, inconsultation with Dr. Jones. Mrs. G. I was

informed by the doctor, had been in laboursixteen hours; the waters were evacuatedearly in her labour ; her pains, frequent and

brisk ; but there wa not the least dispositionin the sof parts to dilate.f

*See Medical Museum, vol. IL. No. 1. p. 27.t This patient, like the one whose case was formery

I sat down to examine our patient, andfound the os externum scarcely large enoughto admit the finger, and it was mounted upclosely against the symphysis pubis, in conse-quence of the perinaeum being very much dis-tended by the head of the child. The os uteri

was rigid and but little opened; a kind of bri-

dle or small column of flesh ran from the in-ferior edge of the os pubis, and lost itself inthe perinteum below; against this the head

was firmly pressed. The head was situated

paturally, and so far advanced, that the vertex

given,* had suffered a lacerationofthe perimeum to a verygreatextent; the parts after a considerable lapse of time healed up,but so unfortunately, as almost entirely to obliterate thethe vagina. I was called upon for my advice when in thissituation, and found the case truly distressing; the passageor vagina was contracted, so as not to exceed in size a com-men quill; the parts extremely callous, and a constant andprofuse discharge of feetid, acrid pus, kept the poor womanin a continual state of misery and ill health. My friend Dr.Physick was also consulted; by a persevering use of spongetents, &c. the parts became sufficiently dilated to admit im-perfectly the venereal congress; soon after, she became preg-nant, and the consequences of this pregnancy, furnish theabove case.

* Medical Repos. vol. II. No. 1. p. 24.

129

was about to emerge from under the arch ofthe pubis, covered with the uterus; it hadbeen thus fixed for nearly six hours previousto my seeing this patient; and all that hadbeen done, was the occasional exhibition oftinct. opil: with steady pressure against theperina um, to prevent the escape of the headthrough it. In this situation of affairs, whatwas to be done ?

My ingenious and much lamented friend,Dr. E. Smith, of New York, immediately afterthe receipt of my former case, suggested thetrial of an infusion of tobacco, in similar cases,to supersede the use of such extensive bleed-ing as had been employed in it; affirming itseffects were very similar to those producedby copious blood-letting; such as nausea, vo-miting, syncope, and consequently relaxation.The idea pleased me, and I was determinedto employ it the first opportunity; the caseunder consideration, I believed to be as fa-vourable a one as could occur, and I accord.

130

ingly proposed it to Dr. Jones; he cheerfull~

agreed to its trial; a strong infusion was made

of the tobacco, and a quantity of it, with some

difficulty, after several ineffectual trials, was

thrown up the rectum. It produced great sick-

ness, vomiting, and fainting; but the desired

relaxation did not take place; we waited some

time longer, but with no better success. In the

course of an hour, or an hour and a half, the

more distressing symptoms produced by the

infusion wore off, and resolving to give the

remedy every chance in our power, we got

our patient, with some difficulty, to consent

to another application of it; its effects were

as before-great distress, without the smallest

benefit; the soft parts remaining equally rigid

as before its exhibition.

Supposing the bridle just spoken of might

have some influence on the development of

the external parts, I divided it, but without

any evident good resulting from it. I now

proposed the remedy that had so completely

181

succeeded in a former case-bleeding nearlyto fainting; this was consented to. We hadour patient placed upon her feet, taking careto have the perinaeum well guarded duringthe operation. Upon taking away about tenounces of blood, she became very faint ;* shewas immediately laid upon her bed; the mostcomplete relaxation had taken place, the for-ceps were applied, and our patient was deli-vered, in a very few minutes, of a fine healthygirl. The mother was put comfortably to bed,and every thing went on in the ordinary wayuntil the sixth day, when she was seized witha violent cholera morbus and convulsions, (towhich complaints she was subject) and died intwelve hours.

This case, notwithstanding its ultimatelyunfortunate termination, fully establishes theinfluence of blood-letting in this very distress-

ing kind of rigidity, and proves it to act dif-

* The subject of this case was a delicate woman, and wontto become very faint, upon the loss of a little bloods

t82

ferently from tobacco, notwithstanding the

latter produces nausea, vomiting, and syn.

cope; and also that the quantity of blood lost

in some instances may be very small to inducethe desired relaxation.

We conceive, that no possible blame can beattached to the bleeding in this case; as thewoman was very well until the sixth day,when a disease, to which she was subject,scar-ried her offi

CASE Xi.On the 26th September, 1800, 1 was caled

to visit the wife of Michael Falkrod; at Frank-

ford, in consultation with Dr. Ruan. She hadbeen in labour twelve or fourteen hours, withher second child ; the pains frequent andstrong, the waters discharged some time; the

head was situated favourably, and completelyoccupied the vagina ; the perineal tumour

" With the first, she had sufferedar extensive laceration ofthe aer cum.

large; the Os externum not larger than a or-

mon finger ring; and admitting the finger

with some difficulty in the absence of pain;

during pain it was thrown against the in-

ferior edge of the pubes, in such a manera

not to admit the finger, or allow it to be re-tained if previously introduced. Externally alarge ciatrix was found running to the very

verge of the anus; internally it could be trac-

ed farther. This cicatrix prevented the unfold-ing of the external parts so effectually, that the

repeated efforts of the uterus for several hourswere insufficient to make then yield, thoughthe head had been closely applied to the.

during that period.

This patient was a strong healthy woman;

considerable fever had been excited; the pulsestrong, frequent, and bard. I proposed bleed-ing ad dliqujum, to which Dr. Rua consented.

We immediately opened a vein, and took about

forty ounces of blood, but as her pains were so

rapid, we were obliged to take it from her in

184

a recumbent posture, and no disposition tosyncope was manifested. This quantity howev-er had some effect, as there was evidently abeginning relaxation, and an abatement of theviolence, and frequency of the pains. Wenow agreed upon a second bleeding, and tohave it taken in an erect situation. We, withsome difficulty, effected this; when upon takingfive and twenty or thirty ounces more she faint-ed; she was laid upon the bed, and in a fewminutes, by the forceps, was delivered of a finehealthy boy. Our patient recovered rapidlywithout accident or drawback.

CASE XX.February 26, 1808. I was called to the same

woman in labour with her third child; the samecircumstances attended, and the same remedywas employed with a similar effect. This casewas witnessed by Mr. Bond, an ingeniousyoung gentleman of Baltimore.

185

CASE XXI.

1792, Aug. 17. Mrs. T. -- , aged 28 years,

in labour with her first child; the pains com-

menced regularly and pretty severely for some

time; they then became more desultory both

in recurrence and in force-she took from the

midwife stimulating drinks, which rather in-

creased her unpleasant feelings, such as a sense

of suffocation, heat and pain all over the abdo-

men, sickness at stomach, 4c. without aug-

menting the force or frequency of her pains;

-when I was called to her she was labouring

under all the distressing sensations just men-

tioned, together with a depressed pulse, fre-

quent sighing, great uneasiness, and apprehen-

sion-the mouth of the uterus was not much

dilated, though quite unresisting when attempt..

ed to be stretched; its edges,were thickened,

but not tense; when pain came on very little

impression was made on the child, and the

mouth of the uterus rather contracted than

opened. As much oppression about the pre-

cordia attended, and great heat in the abdo-

men, I determined on bleeding her; I took from

her arm about twenty ounces before the op-pression and heat were much diminished; butas these were relieved, though not removed,

and the pulse acquired vigour by the opera.

tion, I was induced to go on until these unpleasant symptoms were subdued; this hap-pened by the loss of about ten or twelve

ounces more-I tied up the arm quickly, asthe pains had now very much increased, andsat by the patient; and in about twenty mi-nutes she was safely delivered.

CASE XXII.Mrs. W-, June 1oth, 1805, was taken in

labour with her tenth child; her pains begansmartly, but soon ceased almost entirely-she

continued in this situation from ten in the

evening until six the next morning, at which

time I was called; I found her with nearly

all the symptoms related in case xxi. I bled her

about twenty ounces, pain immediately came

on, and she was quickly delivered.

I 86

187

I had very little prospect of relieving casexxi. in the manner I did, as at that time I was

not so well acquainted with this particular

kind of case, or of the remedy proper for it;but since this time, many cases of the kind

have occurred, and all have been speedily re-lieved in the manner just related.

CASE XXIII.1798, Dec. 18th. I was called to Mrs. Z--,

in labour with her third child; she had beenin labour eight and forty hours; waters dis-charged, thirty-six; the uterus well dilated;pains severe, but no advancement of the la-bour; during the pain the child's head, whichwas well situated, would be forced down, but

as soon as it ceased it would again be retract-

ed; this had been the case for many hours be-

fore I saw her. In order to ascertain the cause

of this delay, I introduced my hand into the

uterus, and presently found the cause of the

child not advancing; a circle, as it were, of

188

the uterus had closed between the shoulders

of the child and the head, which preventedtheir passing. I bled her to fainting; pains

soon came on, and she was quickly delivered.

Cases of this kind have frequently occurred

to me; but in some cases I have been obligedto turn, after the bleeding, (which before was

impossible) and in one or two others I have

been obliged to use the forceps. These cases

resemble each other so much in almost every

respect, that I do not think it necessary to de-

tail but one.

Having given an account of a variety ofcases in which blood-letting has been useful, andsome others, where the labour could not, with-out the most serious evils resulting, be termi-nated without it, I shall close my remarkswith observing, that we must not consider theuse of this remedy confined to the immediatestate of the patient, but extended to her futurehealth and happiness. I look upon it as a pre-

189

ventive to fever, scirrhus, abscess, and con-gestions of various kinds, to which the visceraare but too much exposed, from badly treatedlabours.-Where is the woman who is married,had children, and is in bad health, that doesnot date her illness from one of her lyings-in? Ican with confidence assert, I have never seenpuerperal fever, milk abscess, or the swelledleg, take place, in any one patient who hadsuffered large or repeated bleedings duringtheir labour; it seems to ward off every blowaimed at the puerperal state.

Di.fculty arising from want of force in theUterus, &c.

Besides the causes of difficulty we have al-ready enumerated, we frequently meet withcases in which the uterine efforts are entirelyunavailing, although every thing, as regards

140

position and relaxation, are favourable; thelabour is, of consequence, much delayed.

This situation of the uterus may arise froman original want of power, or it may be owingto its being much exhausted by previous ex-

ertion; but both these cases, as far as my ob.servations have extended, are relieved by thesame remedy, viz. the ergot or the secale cor-nutum.

This remedy has been introduced into prac-tice under very strong evidences in its favour;for few substances of the Materia Medicahave supported an equal character under suchfrequent and varied application.

It would appear, from all I have been ableto collect, and from all I have observed, thatit rarely fails or disappoints, when properlyprescribed; or where too extravagant or im-proper expectations were not entertained.That it is not competent to every case of dif -

141

ficult labour must be admitted, for who could

expect to find a remedy in any one article for

the various contingencies affecting this process?

We gain much whenever we become possess-

ed of a sure remedy for any one disease; and

could we be uniformly progressive in such

acquisitions, we should soon be left without

opprobria medicorum.

The ergot was introduced to our notice

principally by Drs. Stearns and Akerly. The

former appears to have had very ample expe-

rience in its use; and from the latest accounts

which I have seen, from that gentleman, on

this subject, it would appear that it had not

forfeited its character in his hands.

The ergot, as an article of the Materia Me-

dica, is by no means a new remedy; but its

virtues appear to have been very much ne-

glected, as no authority which I have in my

possession, among the English writers, men-

tion it. But in the Dict. Rais. Univers. d'Hist.

142

Natur. by Bomare, we find the following no-

tice of this substance, under the article "Sei-

gle."

"On lit dans le Journal de Physique, Aot, 1774, que ma-

dame Dupille pros Chaumont en Vixen, et dont la principaleoccupation semble ttre le soulegenent des maiheureux qui

manquent de secours et qui en out besoin, a fait prendred'apres les experiences de madame sa mere, a des femmesqui avoient de la peine a accoucher, plein un de coudred'ergot pulverise et delayr soit dans clu vin ou de l'eau, oudu bouillon : le travail de l'accouchemeut, lorsque l'enfantse presente bien, se termnoit dans le quart d'heure, et cesfemmes n'ont point etc incommodees du lusage d'un tel re-made."

From this it would appear that this sub-stance was in familiar use prior to the year(774, and was prescribed for the very cases

for which it is at this moment given. And that

the effects, noticed after its exhibition, were

as promp~t as they are now found to be.

The mode of exhibiting this drug does not

appear to be very material; I have given it

both in substance and by infusion, withoutexperiencing any diference in effect.

I48

The quantity to be given appears to bepretty well decided; namely, one scruple at adose, and repeated in fifteen or twenty mi-

nutes, until a drachm be given, should neces-sity demand it; it is given in this quick suc-

cession, as it would seem that, if it produceno effect in this time, it will not be moresuccessful if a greater interval be allowed toelapse. The quantity here spoken of wouldseem to entirely comport with the dose exhi-bited by madame Dupille.

I have ventured on the use of the ergot ina case for which I never knew it to be pre-scribed, namely, to bring away the placentaafter abortion; and from its entire success inthis instance, am disposed to regard it as avaluable addition to our present means. It willbe confessed by all who have experience inmidwifery, that the retention of the placenta,in the earlier months of pregnancy, is some-times productive of great inconvenience; andthat we are almost exclusively obliged to rely

144

on the efforts of nature to achieve its delive-

rance; and that before this is effected, the wo-man is subjected to serious evls, particularlyin hot weather. It is no unfrequent occurrence

for the uterus to cease to act for several days

after the expulsion of the f&etus; and the pa-tient, during this time, suffers from anxiety as

well as from the extent and foetor of the dis-

charge. I have seen fever induced, which has

not been relieved until after the casting offof

the placenta.

This remedy is regarded as a stimulant of

no mean power; but I must confess I have

never witnessed any direct operation upon

the sanguiferous system. I have carefully

watched the pulse in a number of instances,

but could never detect any influence upon it;

I have therefore, of late, paid little attention

to the state of the system, when about to ex.

hibit it. Its operation appears to be very eva-

nescent, and to be exclusively confined to the

muscular fibres of the uterus. Indeed, it ap.

145

pears to be one of those rare substances,

which is justly intitled to the name of spei-fic; and sems completely to confirm the con-jecture, hazarded many years ago, that weshould be able to prescribe internal remedieswith as much certainty for a too feeble con-

traction of the uterus, as we do for an inter-

mittent fever. See page 17 of this Essay.

The cases in which this remedy however isexclusively indicated, are, it must be confess-ed, but few; but in these few it appears inva-luable.

We consider the following situations as theproper ones for the exhibition of this drug.

First. Where the labour has been long pro-

tracted from the rigidity of the soft parts; andthe uterus had, from the long continuance ofits efforts, become exhausted or weakened be-low the power required to effect delivery;and although the uterus and external parts

T

146

were then in a state of relaxation, yet to ena-

ble the child to pass through them, requiredstronger contractions than the uterus could

yield.

Second. Where the soft parts are in pro-per condition for the passage of the child, butwhere the uterus lends its aid so feebly that

delivery cannot be effected without more vi-

gorous efforts from this viscus.

Third. Where every thing is in propertrain; where the efforts of the uterus thoughslow, but not very powerful, yet if sufficientlylong continued may effect the delivery, andthe labour complicated by any accident whichwould render its speedy termination desira-ble; such as a prolapsus of the cord, moderateflooding, severe cramps, c. Vc.

Fourth. Where all the circumstances ob-tained that were last mentioned, with the ex-

ception of the accidents enumerated. It would

147

in this case be desirable, and I conceive pra-

per, to abridge the woman's sufferings by theuse of the ergot.

Fifth. Where the head of the child hasbeen separated from its body, and left withinthe uterus, as has been ingeniously suggestedby Mr. Beesly of New Jersey, and now astudent of medicine in this University. In thiscase it bids fair to be a valuable medicine.

Sixth. Where the placenta has been pre-

vented being thrown off from want of power

in the uterus.

Seventh. In dysmenorrhoea, as recommend-

ed by Dr. Physick. There is no one circum-

stance connected with the use of the ergot,

that so justly excites our surprise, as the

promptitude of its action. In some cases it

scarcely has time to arrive in the stomach,

before we observe its effects manifested on the

uterus; so sudden, and so efficient are its

148

powers sometimes, as to almost make us

challenge its agency.

But it must be confessed that the ergot, likeevery other remedy, will have its defeats; but

these occur so rarely, where properly em-

ployed, that they scarcely deserve to be men-

tioned. I am aware that in advancing this sen-

timent, I am not supported by every practi-

tioner who has employed the ergot, for someone or two have informed me, they had given

it in very large doses without any advatagewhatever. I cannot doubt their statement,they could have no motive to mislead; yet Iam confident the failure must have originatedfrom a bad quality of the ergot, or from in-

ordinate expectation. It would seem from some

late experiments made on this substance inFrance, that there exists a considerable dif-

ference in its quality, and from this circum-

stance, should in general be much moredis-posed to attribute failure to a bad sort havingbeen exhibited.

149

At all events, there sufficient testimonyin its favour, to induce a trial of it in the easesand under the circumstances above mention-ed. We shall now relate a few cases from

among a number, as confirmatory of its powers..

CASE I.I was called on the 21st December, 1817,

in consultation, to Mrs. M. who had been in

labour sixteen hours; it was a first child, and

the lady was pretty far advanced in life, namely

28 yeas. The waters discharged early iulabour; the pains frequent and strong; theuterus dilated after a few hours so that thechild's head passed it, and every expectationwas entertained that the labour would finishpromptly; in this the physician experienceda disappointment; the head was at the inferiorstrait, and the vertex was applied to thearch of the pubes. Pains still frequent, butgradually became weaker. After waiting sixhours for the delivery, I was sent for. Ifound the patient suffering much from a ge-

150

neml pain over the abdomen, some fever, andgreat restlessness; pains were frequent but in-

efficient; the head was about to emerge from

under the arch of the pubes, but the painswere not of sufficient strength to depress the

parietal bones below the tubers of the ischia.

I waited about twenty minutes to see the ef-fect of the pains, and during each assisted theproper adaptation of the head to the lower

strait; that is, I assisted in turning the face

exactly into the holltw of the sacrum, so that

each limb of the lambdoidal suture was appli-

ed to corresponding portions of the legs of

the pubes. By this I diminished resistance and

aided the efforts of the uterus to this end. But

all this was unavailing, the pains flagged more

and more, and it was agreed to give a scruple

of the ergot, and repeat it should it be neces-

sary; the second dose was given in twenty

minutes after the first, although there appear-

ed an evident increase of power from the first;

in twenty minutes more she was delivered

15i

of a very large healthy boy; nothing worthyof note occurred after the delivery.

CASE II.May 30, 1817, at eight o'clock P. M. I was

called to Bush-Hill to attend Mrs. M. C. Shewas the mother of several children; extreme-

ly delicate and feeble. Her pains were weakand a long time apart; sometimes would notrecur for an hour. On the 31st, at eight o'clockA. M. made an examination, and found theos tinca dilated and very yielding, the painsstill very slow; during a pain, I gently stretch-ed the os uteri, with a hope of exciting astronger action, but failed of success; and asthe parts were well disposed, I ruptured themembranes without any advantage. At twoo'clock P. M. I gave a scruple of the ergot,and in fifteen minutes more repeated it; thepains came on rapidly and with great force,and in a quarter of an hour more she wassafely delivered.

ft52

This case was one of the m strikingstances of the influence of the ergot l verwitnessed; and its specif action, if we may

so term it, was most prompt and efficacious, for

-it succeeded in producing contraction, when a

very powerful means (rupturing of the mem-

branes) had failed. I was in this case ndud

to rupture the membranes f two reasons:First, that by the evacuation of the water,

the uterus miht be stimulated to action,by coming in contact with the child's body

secondly, and by this contraction, to prevent

a flooding from atony.

CASE III.

June 8, f8i7, I wa called to Mr. B. in

labour with her first child. She had been poorly,asthey called it, all nigh but towards day.

flg.t her pains became very smart, and I was

sent for. She wa twenty-five years of ae,

stout made and very firm. Her labour ad vaned very well, the soft parts yielded withoutmruch reluctance after a bleeding of about

158

twenty ounces, the waters escaped by the force

of pain, and the head sunk into the lower

strait in the sixth position. It for some time

advanced as rapidly as such a presentation

would permit, but the pains suddenly became

weak, though pretty frequently repeated. I

waited two hours, in the expectation of their

force being recruited, but they seemed weaker

and more tardy than before. I sent for a drachm

of ergot, and gave one third part of it without

any advantage; a second portion was given in

twenty minutes, and the pains began to 'in-

crease, when at the expiration of fifteen mi-

nutes more, the other portion was given; the

pains in a few minutes afterwards became

powerful and frequently repeated, and in an

hour more she was safely delivered.

Had this been a case of the first or second

presentation, the child would have been de-

livered sooner, as the force of the pains and

the disposition of the parts were favourable

to a rapid issue.

154

CASE IV.

September toth, 1818, Mrs. --- , wasdelivered of twins at the fifth month, after afew hours endurance of pain; some htemor-rhagy attended, but it was not threatening;the ova opened, and the foetuses were thrownoff; a slight flooding followed. After a fewhours more of moderate pain, it ceased, andfour days elapsed without it returning; thedischarge became offensive, and considerabletenderness of the belly was felt, and somefever was excited; the fever every night ter-minated in profuse sweating.

As the action of the uterus did not returnto throw off tho placenta, and as there wassome unpleasant symptoms present, I thoughtit proper to attempt the renewal of the uterineefforts; for this purpose I ordered a ilrachmnof the powdered ergot to be divided into threeparts; one to be given every half hour, untilpain should be excited. Two doses were given,

455

and the uterus was immediately roused to

brisk action, and the placenta thrown off.

The second dose of the ergot was not neces-

sary, but the anxiety of the patient induced

her to take it, although pain had been excited

by the first.

After the expulsion of the placenta the con-

tractions of the uterus were calmed by lauda-

num. My patient, after the lapse of three

days, was persuaded that one of the placenta

remained undischarged, and, without consult-

ing me, took the remaining portion of the

ergot, which had the effect of renewing the

painful contractions of the uterus, which wereagain relieved by opium; nothing untoward

followed; my patient recovered rapidly afterthis period.

From all then that we know at present, we

are justified in saying, that this drug appearsto have a very decided action upon the ute-rine fibre, exciting them to contraction when-

156

ever exhibited for a considerable number of

days after the expulsion of the uterine con-

tents; and that the only precaution to be ob-

served in the use of it is, that it must not be

administered until the mouth of the uterus

and external parts are well dilated or very

favourably disposed to this state.

THE END.

4 '

;

1 1 1 lp S R i11

yA<i7

"r II _ 7t' o Si1fi s {} i

I~~~~/ v/ -'z'

r a ,jI

I &' { _j s'i L fli

r P - {ftrF z~tF x yy ... :f . !t